Provider Demographics
NPI:1821477191
Name:HAWK, JENNIFER NICOLE (LMT, AT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:HAWK
Suffix:
Gender:F
Credentials:LMT, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1506
Mailing Address - Country:US
Mailing Address - Phone:419-376-7967
Mailing Address - Fax:
Practice Address - Street 1:536 PEARL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2730
Practice Address - Country:US
Practice Address - Phone:419-352-8946
Practice Address - Fax:419-352-8947
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OH33.02228-H-K225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer