Provider Demographics
NPI:1366636011
Name:GREEN, JENNIFER MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 SPRING GARDEN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:DE LEON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32130-4210
Mailing Address - Country:US
Mailing Address - Phone:386-985-5783
Mailing Address - Fax:
Practice Address - Street 1:305 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8181
Practice Address - Country:US
Practice Address - Phone:386-676-3130
Practice Address - Fax:386-676-7572
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19986225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant