Provider Demographics
NPI:1497750558
Name:DISNEY, JENNIFER N (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N
Last Name:DISNEY
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 1:1263 HOSPITAL DR NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2172
Mailing Address - Country:US
Mailing Address - Phone:812-738-8136
Mailing Address - Fax:812-738-3155
Practice Address - Street 1:1263 HOSPITAL DR NW
Practice Address - Street 2:SUITE 250
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2172
Practice Address - Country:US
Practice Address - Phone:812-738-8136
Practice Address - Fax:812-738-3155
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200482180Medicaid
INP00861448OtherRAILROAD MEDICARE
IN193920HMedicare PIN
INM400015585Medicare PIN