Provider Demographics
NPI:1801204011
Name:COULSON, JENNIFER LILLIE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LILLIE
Last Name:COULSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GUNNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:257 W KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5009
Practice Address - Country:US
Practice Address - Phone:336-627-4263
Practice Address - Fax:336-627-4266
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003357225100000X
NC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist