Provider Demographics
NPI:1740828391
Name:JENNINGS IRWIN, TARA MARIA (PTA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIA
Last Name:JENNINGS IRWIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 JUNIPER TRACK DR
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-9598
Mailing Address - Country:US
Mailing Address - Phone:352-208-3233
Mailing Address - Fax:
Practice Address - Street 1:11962 CR 101 #104
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162
Practice Address - Country:US
Practice Address - Phone:352-693-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29877225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant