Healthcare Provider Details

I. General information

NPI: 1912795220
Provider Name (Legal Business Name): JENNIFER BROCK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER AVERY PT

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 US HIGHWAY 17 STE 2A
RICHMOND HILL GA
31324-3795
US

IV. Provider business mailing address

2709 US HIGHWAY 17
RICHMOND HILL GA
31324-3796
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-5699
  • Fax:
Mailing address:
  • Phone: 912-756-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12794
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: