Provider Demographics
NPI:1003964560
Name:HOLBOURN, JENNIFER (PT MOMT FAAOMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HOLBOURN
Suffix:
Gender:F
Credentials:PT MOMT FAAOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S COOPER ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5351
Mailing Address - Country:US
Mailing Address - Phone:901-272-2822
Mailing Address - Fax:901-272-2823
Practice Address - Street 1:612 S COOPER ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5352
Practice Address - Country:US
Practice Address - Phone:901-272-2822
Practice Address - Fax:901-272-2823
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729247Medicaid
TN3729247Medicaid