Provider Demographics
NPI:1780848002
Name:CRISP, JENNIFER L (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CRISP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MEDICAL PLAZA LANE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858
Mailing Address - Country:US
Mailing Address - Phone:606-632-1188
Mailing Address - Fax:606-632-0075
Practice Address - Street 1:149 MEDICAL PLAZA LANE
Practice Address - Street 2:SUITE A
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858
Practice Address - Country:US
Practice Address - Phone:606-632-1188
Practice Address - Fax:606-632-0075
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist