Provider Demographics
NPI:1285154344
Name:GONZALEZ, JENNIFER PAIGE (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PAIGE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12195 MAGNOLIA CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-7184
Mailing Address - Country:US
Mailing Address - Phone:404-797-7240
Mailing Address - Fax:
Practice Address - Street 1:5835 CAMPBELLTON RD SW
Practice Address - Street 2:304
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8014
Practice Address - Country:US
Practice Address - Phone:678-755-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1005225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant