MEDICARE: MS. JENNIFER J THEOS 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	21101	FL

General Provider Information

NPI Number	:	1104193101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER J THEOS PTA

Provider Business Mailing Address
First Line	:	13211 WHITEHAVEN LN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1518
Country	:	US
Telephone Number	:	239-247-3096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1333 SANTA BARBARA BLVD
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33991-2803
Country	:	US
Telephone Number	:	239-772-1333
Fax Number	:

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

Provider Enumeration Date	:	11/19/2011
Last Update Date	:	11/19/2011

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