Provider Demographics
NPI:1548295710
Name:BURON, JENNIFER DALE (MPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DALE
Last Name:BURON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15549 PUTMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-7873
Mailing Address - Country:US
Mailing Address - Phone:479-531-7422
Mailing Address - Fax:479-925-7250
Practice Address - Street 1:15549 PUTMAN RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-7873
Practice Address - Country:US
Practice Address - Phone:479-531-7422
Practice Address - Fax:479-925-7250
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U978OtherBLUE CROSS BLUE SHIELD