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General NPI Number Information
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NPI Number | 1346511490
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Entity Type | Individual
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Provider Name | JACQUELYN TIFFANY BRENNER DPT
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Gender | Female
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Dates
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Enumeration Date | 01/21/2012
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Last Update Date | 01/21/2012
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Provider Practice Location Address
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Address Line | 4645 S CLYDE MORRIS BLVD STE 407
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City | PORT ORANGE
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State | FL
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Zip | 32129-3005
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Country | US
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Telephone | 386-763-1771
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Fax | 386-763-3375
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Provider Business Mailing Address
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Address Line | 11808 MEADOW BRANCH DR APT 1128
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City | ORLANDO
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State | FL
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Zip | 32825-5070
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 26059
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License Number State | FL
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