Provider Demographics
NPI:1770763856
Name:FERNANDEZ, JENNIFER S (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:619 E BLITHEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1468
Mailing Address - Country:US
Mailing Address - Phone:415-388-5223
Mailing Address - Fax:
Practice Address - Street 1:619 E BLITHEDALE AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1468
Practice Address - Country:US
Practice Address - Phone:415-388-5223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT4913225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant