Provider Demographics
NPI:1134163538
Name:JOHNSON, JENNIFER JO KOSTIK (DPT, ATC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JO KOSTIK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:KOSTIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:127 SHULTZ ST
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-2220
Mailing Address - Country:US
Mailing Address - Phone:724-277-2365
Mailing Address - Fax:
Practice Address - Street 1:112 WALNUT LN
Practice Address - Street 2:SUITE 10
Practice Address - City:WEST NEWTON
Practice Address - State:PA
Practice Address - Zip Code:15089-1170
Practice Address - Country:US
Practice Address - Phone:724-872-0356
Practice Address - Fax:724-872-6051
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017304L225100000X
PART0035952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer