Provider Demographics
NPI:1518341650
Name:STATLER, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STATLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 LAKE DR
Mailing Address - Street 2:UNIT B
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161
Mailing Address - Country:US
Mailing Address - Phone:210-837-4753
Mailing Address - Fax:
Practice Address - Street 1:1380 LAKE DR
Practice Address - Street 2:UNIT B
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161
Practice Address - Country:US
Practice Address - Phone:210-837-4753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016863225100000X
TX1257253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist