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General NPI Number Information
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NPI Number | 1124592233
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Entity Type | Individual
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Provider Name | JENELLE CONOVER PTA
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Gender | Female
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Dates
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Enumeration Date | 01/11/2019
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Last Update Date | 01/11/2019
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Provider Practice Location Address
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Address Line | 111 LAKESIDE DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-3811
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Country | US
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Telephone | 616-438-2425
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Fax |
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Provider Business Mailing Address
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Address Line | 6884 BYRON LAKES DR SW APT 1B
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City | BYRON CENTER
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State | MI
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Zip | 49315-9766
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502004636
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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