Provider Demographics
NPI:1457867491
Name:WHIDDON, JENNIFER (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WHIDDON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:701-780-4477
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-780-4477
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015336225100000X
NDA2042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist