Provider Demographics
NPI:1811432040
Name:JENNINGS, SHAUNTEL
Entity type:Individual
Prefix:
First Name:SHAUNTEL
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 MAINSTREET LAKE DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2345
Mailing Address - Country:US
Mailing Address - Phone:404-769-7651
Mailing Address - Fax:
Practice Address - Street 1:921 MAINSTREET LAKE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2345
Practice Address - Country:US
Practice Address - Phone:404-769-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003158225200000X
CA11151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant