Provider Demographics
NPI:1942453543
Name:ANDERSON, JENNIFER LEAH (MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEAH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 GATOR LN
Mailing Address - Street 2:
Mailing Address - City:ROUGEMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27572-6527
Mailing Address - Country:US
Mailing Address - Phone:336-364-4389
Mailing Address - Fax:
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-470-7207
Practice Address - Fax:919-470-7232
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist