MEDICARE: JENNIFER J WHITE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	A8497	LA

General Provider Information

NPI Number	:	1164077764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER J WHITE PTA

Provider Business Mailing Address
First Line	:	2002 JOHNSON ST STE 100
Second Line	:
City	:	JENNINGS
State	:	LA
Zip	:	70546-3640
Country	:	US
Telephone Number	:	337-824-4547
Fax Number	:	337-824-4548

Provider Business Practice Location Address
First Line	:	4501 JACKSON ST STE B
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2555
Country	:	US
Telephone Number	:	318-704-0710
Fax Number	:	318-704-0711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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