Provider Demographics
NPI:1083166730
Name:PENDERGRASS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S FORT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3480
Mailing Address - Country:US
Mailing Address - Phone:417-882-0035
Mailing Address - Fax:
Practice Address - Street 1:2800 S FORT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3480
Practice Address - Country:US
Practice Address - Phone:417-882-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024570225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant