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General NPI Number Information
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NPI Number | 1790170884
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Entity Type | Individual
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Provider Name | JENNIFER L. SOUTHERN PTA
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Gender | Female
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Dates
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Enumeration Date | 04/06/2015
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Last Update Date | 04/06/2015
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Provider Practice Location Address
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Address Line | 3008 SHAWNEE DR S
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City | BEDFORD
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State | IN
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Zip | 47421-5282
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Country | US
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Telephone | 812-275-2468
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Fax |
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Provider Business Mailing Address
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Address Line | 101 STEEPLE RIDGE LN
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City | BEDFORD
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State | IN
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Zip | 47421-9776
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Country | US
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Telephone | 812-275-0517
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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 | 06003081A
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License Number State | IN
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