Provider Demographics
NPI:1598839557
Name:THORN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:586 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-1390
Mailing Address - Country:US
Mailing Address - Phone:843-884-7880
Mailing Address - Fax:843-884-6633
Practice Address - Street 1:607 JOHNNIE DODDS BLVD # A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3030
Practice Address - Country:US
Practice Address - Phone:843-884-7880
Practice Address - Fax:843-884-6635
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1742Medicaid
SCGP1753Medicaid
426567Medicare ID - Type Unspecified