Provider Demographics
NPI:1154833762
Name:PRIDMORE, JENNIFER (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PRIDMORE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 E NECESSARY RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1311
Mailing Address - Country:US
Mailing Address - Phone:303-594-3308
Mailing Address - Fax:
Practice Address - Street 1:101 S PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4246
Practice Address - Country:US
Practice Address - Phone:303-594-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer