Provider Demographics
NPI:1609511799
Name:LAURENT, JENNIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:
Last Name:LAURENT
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:PO BOX 1984
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33836-1984
Mailing Address - Country:US
Mailing Address - Phone:407-276-3266
Mailing Address - Fax:
Practice Address - Street 1:400 N LAKE HOWARD DRIVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-268-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31056225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant