MEDICARE: JENNIFER M THOENNISSEN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA23456	FL

General Provider Information

NPI Number	:	1033998612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M THOENNISSEN PTA

Provider Business Mailing Address
First Line	:	1533 MARICOPA RD
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-4123
Country	:	US
Telephone Number	:	941-468-7078
Fax Number	:

Provider Business Practice Location Address
First Line	:	14580 TAMIAMI TRL # DE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-2708
Country	:	US
Telephone Number	:	941-200-2570
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	09/25/2023

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