Provider Demographics
NPI:1952649931
Name:PRADO, JENNIFER LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PRADO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:HAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:8357 NE HIGHWAY 69
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-8114
Mailing Address - Country:US
Mailing Address - Phone:816-632-9638
Mailing Address - Fax:
Practice Address - Street 1:1111 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-2005
Practice Address - Country:US
Practice Address - Phone:816-632-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008032034225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant