Provider Demographics
NPI:1528187119
Name:GOLDNER, JEANINE DAVID (PT)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:DAVID
Last Name:GOLDNER
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 1:1125 TIMBERLANE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-3564
Mailing Address - Country:US
Mailing Address - Phone:317-432-5962
Mailing Address - Fax:317-253-6547
Practice Address - Street 1:1125 TIMBERLANE ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-3564
Practice Address - Country:US
Practice Address - Phone:317-432-5962
Practice Address - Fax:317-253-6547
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001889 A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist