Provider Demographics
NPI:1649298506
Name:HOUSTON, JENNA LYNNE (MED, ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:LYNNE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 RIVER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7466
Mailing Address - Country:US
Mailing Address - Phone:478-335-8726
Mailing Address - Fax:
Practice Address - Street 1:MOUNT DE SALES ACADEMY
Practice Address - Street 2:851 ORANGE ST
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-751-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
GAAT0012192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer