Provider Demographics
NPI:1114957131
Name:JENNESS, KRYSTAL (PT)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:JENNESS
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 1:303 LLOYD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-4403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1282 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VT
Practice Address - Zip Code:05454-9534
Practice Address - Country:US
Practice Address - Phone:802-849-9308
Practice Address - Fax:802-849-9752
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400000972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT29696OtherBCBS OF VT PROVIDER #
VT1006936Medicaid
VT9150484OtherCIGNA PROVIDER #
VT364674OtherMVP PROVIDER #
VT364674OtherMVP PROVIDER #