Healthcare Provider Details

I. General information

NPI: 1033665211
Provider Name (Legal Business Name): JENNA KAY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA ROBERTS

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 PONTE VEDRA PARK DR SUITE 300
PONTE VEDRA FL
32082-6619
US

IV. Provider business mailing address

PO BOX 441146
KENNESAW GA
30160-9522
US

V. Phone/Fax

Practice location:
  • Phone: 904-280-3440
  • Fax:
Mailing address:
  • Phone: 678-403-3632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT31798
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: