Healthcare Provider Details

I. General information

NPI: 1144465485
Provider Name (Legal Business Name): JENNIFER RENEE INNIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 NORTH MAIN STREET
SALEM AR
72576
US

IV. Provider business mailing address

PO BOX 517
SALEM AR
72576-0517
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2691
  • Fax: 870-895-3306
Mailing address:
  • Phone: 870-895-2691
  • Fax: 870-895-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2287
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: