Provider Demographics
NPI:1831478270
Name:WILLIAMS, JENNIFER LEE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WILLIAMS
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 1:118 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4310
Mailing Address - Country:US
Mailing Address - Phone:386-252-2400
Mailing Address - Fax:386-252-2414
Practice Address - Street 1:118 ORANGE AVE
Practice Address - Street 2:1630 MASON AVE
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4310
Practice Address - Country:US
Practice Address - Phone:386-252-2400
Practice Address - Fax:386-252-2414
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22788225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant