Healthcare Provider Details

I. General information

NPI: 1609511799
Provider Name (Legal Business Name): JENNIE LAURENT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N LAKE HOWARD DRIVE
WINTER HAVEN FL
33880
US

IV. Provider business mailing address

PO BOX 1984
DAVENPORT FL
33836-1984
US

V. Phone/Fax

Practice location:
  • Phone: 863-268-2608
  • Fax:
Mailing address:
  • Phone: 407-276-3266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPT31056
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: