Provider Demographics
NPI:1467900712
Name:WATHNE, JENNIFER B (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:WATHNE
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 1:540 ROUTE 10 W
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2026
Mailing Address - Country:US
Mailing Address - Phone:973-366-6615
Mailing Address - Fax:973-366-9427
Practice Address - Street 1:540 ROUTE 10 W
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2026
Practice Address - Country:US
Practice Address - Phone:973-366-6615
Practice Address - Fax:973-366-9427
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00310900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant