Provider Demographics
NPI:1912486945
Name:PEDRAZA, JENNIFER (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PEDRAZA
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 1:3171 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-6019
Mailing Address - Country:US
Mailing Address - Phone:832-459-3321
Mailing Address - Fax:
Practice Address - Street 1:4400 GULF AVE
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-3717
Practice Address - Country:US
Practice Address - Phone:832-459-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2076437225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant