Provider Demographics
NPI:1205380284
Name:VAN GHEEM, JENNIFER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VAN GHEEM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MILROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3606 E BASELINE RD UNIT 218
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-9613
Mailing Address - Country:US
Mailing Address - Phone:815-751-6916
Mailing Address - Fax:
Practice Address - Street 1:2055 W FRYE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6277
Practice Address - Country:US
Practice Address - Phone:480-821-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist