Provider Demographics
NPI:1669647905
Name:PRIDGEN, JENNIFER LEIGH (PTA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:PRIDGEN
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 1:2212 PANOLA ST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-2228
Mailing Address - Country:US
Mailing Address - Phone:252-823-8100
Mailing Address - Fax:
Practice Address - Street 1:200 TRADE ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-5055
Practice Address - Country:US
Practice Address - Phone:252-823-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3473225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2251500000XOtherPT