Provider Demographics
NPI:1649225624
Name:LANDER, JENNIFER JORDAN (P T)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JORDAN
Last Name:LANDER
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-0039
Mailing Address - Country:US
Mailing Address - Phone:912-653-4863
Mailing Address - Fax:912-653-7979
Practice Address - Street 1:163 WINDING WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321-5535
Practice Address - Country:US
Practice Address - Phone:912-547-0181
Practice Address - Fax:912-653-7979
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X
GA42882251N0400X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000859075AMedicaid