Provider Demographics
NPI:1740413384
Name:BROWN, JENNIFER LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BROWN
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 1:200 BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-2802
Mailing Address - Country:US
Mailing Address - Phone:870-884-0018
Mailing Address - Fax:870-325-6316
Practice Address - Street 1:1717 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-7104
Practice Address - Country:US
Practice Address - Phone:870-352-7975
Practice Address - Fax:870-352-8163
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant