Provider Demographics
NPI:1518211697
Name:PEARSON, JENNY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:PEARSON
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 1:263 S SR 49
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-9790
Mailing Address - Country:US
Mailing Address - Phone:219-309-5461
Mailing Address - Fax:
Practice Address - Street 1:1201 CUMBERLAND XING
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2192
Practice Address - Country:US
Practice Address - Phone:219-286-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12214-24225100000X
OHPT.014010225100000X
IN05011733A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN714850269Medicaid