Provider Demographics
NPI:1568793248
Name:EVERSMAN, JENNY SUE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:SUE
Last Name:EVERSMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5837 W WALLEN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9363
Mailing Address - Country:US
Mailing Address - Phone:260-715-2850
Mailing Address - Fax:
Practice Address - Street 1:2827 NORTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2900
Practice Address - Country:US
Practice Address - Phone:260-715-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002991A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist