Provider Demographics
NPI:1598815847
Name:EDWARDS, JENNIFER S (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-0428
Mailing Address - Country:US
Mailing Address - Phone:321-795-6422
Mailing Address - Fax:
Practice Address - Street 1:1315 NW 21ST AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1959
Practice Address - Country:US
Practice Address - Phone:352-493-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 15995225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant