Provider Demographics
NPI:1689632408
Name:ANDERSON, JENNIFER (LPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BOSTELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1827
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43301-1827
Mailing Address - Country:US
Mailing Address - Phone:740-383-8022
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1050 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-383-8022
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2596874Medicaid
OH27398721400OtherWORKERS COMP
OH000000368964OtherANTHEM
P00253351OtherTRAVELERS MEDICARE
P00253351OtherTRAVELERS MEDICARE