Provider Demographics
NPI:1417908070
Name:WARREN, JENNIFER (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WARREN
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 1:829 BELLE RIVE DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-5012
Mailing Address - Country:US
Mailing Address - Phone:870-919-1754
Mailing Address - Fax:
Practice Address - Street 1:315 E UNION AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3235
Practice Address - Country:US
Practice Address - Phone:870-563-1331
Practice Address - Fax:870-563-1334
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157435721Medicaid