Provider Demographics
NPI:1144487190
Name:CHAMPA, JENNIFER K (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:CHAMPA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S LAMAR BLVD APT 413
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-1094
Mailing Address - Country:US
Mailing Address - Phone:512-671-0930
Mailing Address - Fax:
Practice Address - Street 1:3948 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3303
Practice Address - Country:US
Practice Address - Phone:323-289-8601
Practice Address - Fax:323-289-8603
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114292225100000X
CA32283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist