Provider Demographics
NPI:1437276714
Name:TRICKETT, JENNIFER LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:TRICKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 351B
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:WV
Mailing Address - Zip Code:26374-9611
Mailing Address - Country:US
Mailing Address - Phone:304-265-4562
Mailing Address - Fax:
Practice Address - Street 1:8 ROSE ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1678
Practice Address - Country:US
Practice Address - Phone:304-265-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant