=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417908070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER WARREN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 02/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E UNION AVE
-----------------------------------------------------
City | OSCEOLA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72370-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-563-1331
-----------------------------------------------------
Fax | 870-563-1334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 829 BELLE RIVE DR
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72364-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-919-1754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA2057
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------