Provider Demographics
NPI:1902142904
Name:FAWL, JENNA (CPTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:FAWL
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 SW ALBRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-4707
Mailing Address - Country:US
Mailing Address - Phone:785-478-9500
Mailing Address - Fax:
Practice Address - Street 1:3220 SW ALBRIGHT DR
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-4707
Practice Address - Country:US
Practice Address - Phone:785-478-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant