Provider Demographics
NPI:1124141460
Name:JENGO, NYAWOH WINNIFRED (PTA)
Entity type:Individual
Prefix:MS
First Name:NYAWOH
Middle Name:WINNIFRED
Last Name:JENGO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:NYAWOH
Other - Middle Name:WINNIFRED
Other - Last Name:JENGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:2127 S 58TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-5907
Mailing Address - Country:US
Mailing Address - Phone:215-727-3578
Mailing Address - Fax:
Practice Address - Street 1:2100 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1400
Practice Address - Country:US
Practice Address - Phone:215-685-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE007796225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant