Provider Demographics
NPI:1255668513
Name:PITZER, JOLYN M (PT)
Entity Type:Individual
Prefix:
First Name:JOLYN
Middle Name:M
Last Name:PITZER
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 1:5310 MERCHANDISE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5140
Mailing Address - Country:US
Mailing Address - Phone:260-484-9491
Mailing Address - Fax:260-484-9451
Practice Address - Street 1:5310 MERCHANDISE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5140
Practice Address - Country:US
Practice Address - Phone:260-484-9491
Practice Address - Fax:260-484-9451
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010162A225100000X
IN06003319A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05010162AOtherLICENSE
IN06003319AOtherLICENSE