Provider Demographics
NPI:1144465485
Name:INNIS, JENNIFER RENEE (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:INNIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0517
Mailing Address - Country:US
Mailing Address - Phone:870-895-2691
Mailing Address - Fax:870-895-3306
Practice Address - Street 1:679 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576
Practice Address - Country:US
Practice Address - Phone:870-895-2691
Practice Address - Fax:870-895-3306
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2287225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant