Provider Demographics
NPI:1457769713
Name:MOLTZ, JENNIFER L (PT, DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MOLTZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SAN REMO DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6343
Mailing Address - Country:US
Mailing Address - Phone:802-865-0010
Mailing Address - Fax:802-865-0050
Practice Address - Street 1:23 SAN REMO DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6343
Practice Address - Country:US
Practice Address - Phone:802-865-0010
Practice Address - Fax:802-865-0050
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0102690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN3242Medicaid
VTVN3242Medicare PIN