Provider Demographics
NPI:1659676104
Name:BAZEMORE, JENNIFER RICHARDS (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RICHARDS
Last Name:BAZEMORE
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 1:3139 MILFORD CHASE SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-5786
Mailing Address - Country:US
Mailing Address - Phone:404-788-3419
Mailing Address - Fax:770-521-9210
Practice Address - Street 1:3139 MILFORD CHASE SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-5786
Practice Address - Country:US
Practice Address - Phone:404-788-3419
Practice Address - Fax:770-521-9210
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist