Provider Demographics
NPI:1851576615
Name:BRAVO, JENNIFER LEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PTA
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Mailing Address - Street 1:18945 FM 2252
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2562
Mailing Address - Country:US
Mailing Address - Phone:210-651-0027
Mailing Address - Fax:210-651-0029
Practice Address - Street 1:18945 FM 2252
Practice Address - Street 2:SUITE 115
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2562
Practice Address - Country:US
Practice Address - Phone:210-651-0027
Practice Address - Fax:210-651-0029
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX2060098225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant