Healthcare Provider Details

I. General information

NPI: 1942642657
Provider Name (Legal Business Name): JENNIFER M VON ANTZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427 GEX RD SUITE B
DIAMONDHEAD MS
39525-3208
US

IV. Provider business mailing address

251 JOHNSTON ST SE STE 200
DECATUR AL
35601-2515
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-5714
  • Fax: 228-388-0017
Mailing address:
  • Phone: 256-350-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3339
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: