Provider Demographics
NPI:1942642657
Name:VON ANTZ, JENNIFER M (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:VON ANTZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 JOHNSTON ST SE
Mailing Address - Street 2:STE 200
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-350-1764
Mailing Address - Fax:
Practice Address - Street 1:5427 GEX RD
Practice Address - Street 2:SUITE B
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3208
Practice Address - Country:US
Practice Address - Phone:228-388-5714
Practice Address - Fax:228-388-0017
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist