Provider Demographics
NPI:1144568346
Name:WATTERS, JENNIFER DIANE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:WATTERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:KUHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:713 LAUREN DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-2657
Mailing Address - Country:US
Mailing Address - Phone:859-221-8374
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5185
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant