Provider Demographics
NPI:1275652976
Name:ANDERSON, JENNIFER LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ANDERSON
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 1:3946 WORTHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:OH
Mailing Address - Zip Code:43021-9236
Mailing Address - Country:US
Mailing Address - Phone:614-517-2171
Mailing Address - Fax:
Practice Address - Street 1:3946 WORTHINGTON RD
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:OH
Practice Address - Zip Code:43021-9236
Practice Address - Country:US
Practice Address - Phone:614-517-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT9422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPT9422OtherOHIO PT LICENSE