Provider Demographics
NPI:1336428044
Name:GOTANTAS, JENNIFER VOGEL (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:VOGEL
Last Name:GOTANTAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-0013
Mailing Address - Country:US
Mailing Address - Phone:970-306-8609
Mailing Address - Fax:
Practice Address - Street 1:710 N SUMMIT BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-306-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist