Provider Demographics
NPI:1932630514
Name:FONKEN, JENNIFER HOPE (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOPE
Last Name:FONKEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 ENCHANTED FOREST DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-5805
Mailing Address - Country:US
Mailing Address - Phone:512-297-7743
Mailing Address - Fax:
Practice Address - Street 1:12509 ENCHANTED FOREST DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-5805
Practice Address - Country:US
Practice Address - Phone:512-297-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1122893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist