Provider Demographics
NPI:1710656889
Name:ANDERSON, JENNIFER LYNNE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 LINDH RD APT 43
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3746
Mailing Address - Country:US
Mailing Address - Phone:540-550-3466
Mailing Address - Fax:
Practice Address - Street 1:759 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1154
Practice Address - Country:US
Practice Address - Phone:540-550-3466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214677225100000X
MSCP022518T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist