Provider Demographics
NPI:1881855286
Name:ELAM, JENNIFER HAYNES (MSPT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:HAYNES
Last Name:ELAM
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13201 RR 620 N
Mailing Address - Street 2:SUITE 206
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-1011
Mailing Address - Country:US
Mailing Address - Phone:512-450-1300
Mailing Address - Fax:
Practice Address - Street 1:13201 RR 620 N
Practice Address - Street 2:SUITE 206
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-1011
Practice Address - Country:US
Practice Address - Phone:512-450-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1202019225100000X
CAPT28953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist