Provider Demographics
NPI:1730126616
Name:SVENDSEN, JERRY R (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:SVENDSEN
Suffix:
Gender:M
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:426 S ALABAMA ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-3301
Practice Address - Country:US
Practice Address - Phone:317-528-2489
Practice Address - Fax:317-528-3771
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001574A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092831OtherANTHEM
IN201371140Medicaid