=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114978319
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER H FORMAN MSPT PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7134 BOCA POINTE DRIVE
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-3905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-955-9384
-----------------------------------------------------
Fax | 561-392-7395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6860 NW 73RD STREET
-----------------------------------------------------
City | PARKLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-955-9384
-----------------------------------------------------
Fax | 561-392-7395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROBERT J FORMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-289-4692
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | Y911T
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------