Provider Demographics
NPI:1669774493
Name:CHURCHILL, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 EISENHOWER DR
Mailing Address - Street 2:APT #103
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-8124
Mailing Address - Country:US
Mailing Address - Phone:760-420-6495
Mailing Address - Fax:
Practice Address - Street 1:2935 BASELINE RD
Practice Address - Street 2:STE 301
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2366
Practice Address - Country:US
Practice Address - Phone:303-941-1768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37320225100000X
WAPT 60535854225100000X
COPTL.0014515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist