Provider Demographics
NPI:1487678090
Name:BARSTROM, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BARSTROM
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 1:31 OLD ROUTE 7
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:401 MONROE TPKE
Practice Address - Street 2:VILLAGE SQUARE MEDICAL OFFICES
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2276
Practice Address - Country:US
Practice Address - Phone:203-445-8691
Practice Address - Fax:203-445-8692
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114979226OtherCARLSON THERAPY GROUP NPI#