Provider Demographics
NPI:1669655205
Name:MOGAVERO, JENNIFER A (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MOGAVERO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 IVORY COAST DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-2269
Mailing Address - Country:US
Mailing Address - Phone:702-236-9454
Mailing Address - Fax:
Practice Address - Street 1:3228 IVORY COAST DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2269
Practice Address - Country:US
Practice Address - Phone:702-236-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1256225100000X
CO8861225100000X
NY016958-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist