Provider Demographics
NPI:1689028615
Name:TOLENTINO, MARY JOCELYNNE SERAJOSE (PT)
Entity Type:Individual
Prefix:
First Name:MARY JOCELYNNE
Middle Name:SERAJOSE
Last Name:TOLENTINO
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 1:1316 WENDELL LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5279
Mailing Address - Country:US
Mailing Address - Phone:706-860-7974
Mailing Address - Fax:
Practice Address - Street 1:1316 WENDELL LN
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5279
Practice Address - Country:US
Practice Address - Phone:706-860-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004899225100000X
SC2677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist