Provider Demographics
NPI:1760085666
Name:FAWCETT, JERRIE L (DPT)
Entity Type:Individual
Prefix:
First Name:JERRIE
Middle Name:L
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2482 OBSIDIAN FOREST VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80951-9766
Mailing Address - Country:US
Mailing Address - Phone:321-525-5327
Mailing Address - Fax:
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist