Provider Demographics
NPI:1174956429
Name:HARRIS, JENNIFER (PTA23996)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PTA23996
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8455 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5066
Mailing Address - Country:US
Mailing Address - Phone:352-382-1141
Mailing Address - Fax:
Practice Address - Street 1:8455 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5066
Practice Address - Country:US
Practice Address - Phone:352-382-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23996225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant