Provider Demographics
NPI:1306244975
Name:JARVIS, BRENNA (PTA)
Entity type:Individual
Prefix:MS
First Name:BRENNA
Middle Name:
Last Name:JARVIS
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 1:1924 N LEG RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4451
Mailing Address - Country:US
Mailing Address - Phone:812-243-1179
Mailing Address - Fax:
Practice Address - Street 1:1043 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7318
Practice Address - Country:US
Practice Address - Phone:706-597-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003375225200000X
IN06004984A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA003375OtherGEORGIA PTA LICENSE NUMBER