Provider Demographics
NPI:1770162612
Name:JERNIGAN, TANYA L (PT, DPT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LANDMARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4233
Mailing Address - Country:US
Mailing Address - Phone:307-472-3327
Mailing Address - Fax:307-472-0297
Practice Address - Street 1:300 LANDMARK DR STE B
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4233
Practice Address - Country:US
Practice Address - Phone:307-472-3327
Practice Address - Fax:307-472-0297
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist