Provider Demographics
NPI:1164024816
Name:BAMBROUGH, JENNIFER (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAMBROUGH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 LARK LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-1902
Mailing Address - Country:US
Mailing Address - Phone:262-442-2188
Mailing Address - Fax:
Practice Address - Street 1:404 LARK LN
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-1902
Practice Address - Country:US
Practice Address - Phone:262-442-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12211225100000X
IL070025285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist