Provider Demographics
NPI:1205091675
Name:LOURAINE, JENNIFER JOY
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOY
Last Name:LOURAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7426 TIPPERARY TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-8122
Mailing Address - Country:US
Mailing Address - Phone:260-749-2148
Mailing Address - Fax:
Practice Address - Street 1:7426 TIPPERARY TRL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-8122
Practice Address - Country:US
Practice Address - Phone:260-749-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002434A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant