Basic Information
| Provider Information | |||||||||
| NPI: | 1942642657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON ANTZ | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 JOHNSTON ST SE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563501764 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5427 GEX RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | DIAMONDHEAD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395253208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT3339 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.