Provider Demographics
NPI:1790032654
Name:STEWART, JENNIFER L (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:STEWART
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 1:7111 HIGHWAY 39
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-6370
Mailing Address - Country:US
Mailing Address - Phone:417-839-8291
Mailing Address - Fax:
Practice Address - Street 1:600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1004
Practice Address - Country:US
Practice Address - Phone:417-466-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001974225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant