Provider Demographics
NPI:1992466916
Name:MATTATALL, JENNA RENEE (PTA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:RENEE
Last Name:MATTATALL
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 1:3103 KINGSTON CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-7513
Mailing Address - Country:US
Mailing Address - Phone:561-358-4012
Mailing Address - Fax:
Practice Address - Street 1:2090 PALM BEACH LAKES BLVD STE 900
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6508
Practice Address - Country:US
Practice Address - Phone:561-335-5965
Practice Address - Fax:561-335-5961
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30210208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation