Basic Information
| Provider Information | |||||||||
| NPI: | 1740828391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS IRWIN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 JUNIPER TRACK DR | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344809598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522083233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11962 CR 101 #104 | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526933378 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2019 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 29877 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.