Provider Demographics
NPI:1336664465
Name:VICKERY, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VICKERY
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 1:49 ROSE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-2109
Mailing Address - Country:US
Mailing Address - Phone:609-891-6839
Mailing Address - Fax:
Practice Address - Street 1:49 ROSEHILL RD
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005
Practice Address - Country:US
Practice Address - Phone:609-891-6839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00602400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty