Provider Demographics
NPI:1891013389
Name:HAITHCOCK, JENNIE ELLIS (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:ELLIS
Last Name:HAITHCOCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:ELIZABETH
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2024
Practice Address - Street 1:205 MIDLAND PKWY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8122
Practice Address - Country:US
Practice Address - Phone:843-875-7163
Practice Address - Fax:843-875-7169
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist