Provider Demographics
NPI:1679731020
Name:FORD, JENNIFER LYNNE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:FORD
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 1:557 PARK ST APT 6
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2581
Mailing Address - Country:US
Mailing Address - Phone:208-305-4636
Mailing Address - Fax:
Practice Address - Street 1:557 PARK ST APT 6
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2581
Practice Address - Country:US
Practice Address - Phone:208-305-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2149225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant