Provider Demographics
NPI:1326477308
Name:ENNIS, JENNIFER A (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14524 POTOMAC MILLS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6803
Mailing Address - Country:US
Mailing Address - Phone:703-490-6726
Mailing Address - Fax:703-494-2171
Practice Address - Street 1:14524 POTOMAC MILLS RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6803
Practice Address - Country:US
Practice Address - Phone:703-490-6726
Practice Address - Fax:703-494-2171
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist