Provider Demographics
NPI:1942750484
Name:SULLIVAN, JENNIFER (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 PHILLIPS RD # A
Mailing Address - Street 2:
Mailing Address - City:LEVANT
Mailing Address - State:ME
Mailing Address - Zip Code:04456-4446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:518 PHILLIPS RD # A
Practice Address - Street 2:
Practice Address - City:LEVANT
Practice Address - State:ME
Practice Address - Zip Code:04456-4446
Practice Address - Country:US
Practice Address - Phone:207-240-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4718225200000X
MEMT3547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist