Provider Demographics
NPI:1659691194
Name:VAN VRANCKEN, JENNIFER LANIER (DPT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LANIER
Last Name:VAN VRANCKEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KAY
Other - Last Name:LANIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:335 EGAN DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5426
Mailing Address - Country:US
Mailing Address - Phone:985-707-5212
Mailing Address - Fax:
Practice Address - Street 1:4100 S FERDON BLVD STE C1
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:850-682-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist