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General NPI Number Information
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NPI Number | 1851758817
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Entity Type | Individual
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Provider Name | JENA COURVILLE PTA, ATC
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Gender | Female
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Dates
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Enumeration Date | 01/21/2016
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Last Update Date | 01/21/2016
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Provider Practice Location Address
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Address Line | 1227 LOUISIANA 30 E
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City | GONZALES
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State | LA
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Zip | 70737
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Country | US
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Telephone | 225-647-2060
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Fax |
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Provider Business Mailing Address
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Address Line | 17110 FOUNTAINBLEAU DR
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City | PRAIRIEVILLE
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State | LA
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Zip | 70769-5385
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Country | US
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Telephone | 337-277-3144
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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 | A9100
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATH.200249
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License Number State | LA
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