Provider Demographics
NPI:1295932713
Name:POLIVICK, JENNIFER SUE (PT)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:SUE
Last Name:POLIVICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1761 COUNTY ROAD 1314
Mailing Address - Street 2:
Mailing Address - City:BARDWELL
Mailing Address - State:KY
Mailing Address - Zip Code:42023-9050
Mailing Address - Country:US
Mailing Address - Phone:270-628-3882
Mailing Address - Fax:
Practice Address - Street 1:4747 ALBEN BARKLEY DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6789
Practice Address - Country:US
Practice Address - Phone:270-201-2200
Practice Address - Fax:270-443-6211
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist