Provider Demographics
NPI:1851758817
Name:COURVILLE, JENA (PTA, ATC)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:COURVILLE
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17110 FOUNTAINBLEAU DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-5385
Mailing Address - Country:US
Mailing Address - Phone:337-277-3144
Mailing Address - Fax:
Practice Address - Street 1:1227 LOUISIANA 30 E
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-647-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA9100225200000X
LAATH.2002492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer