Basic Information
| Provider Information | |||||||||
| NPI: | 1497045611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | DEATON | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6508 AMBERSIDE RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871206220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052050527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2011 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A1351 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.