Provider Demographics
NPI:1740298496
Name:JERNEGAN, JEANINE (PT)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:JERNEGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 FOXWORTH LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-1356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 TREMONT ST
Practice Address - Street 2:SUITE 20
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-4738
Practice Address - Country:US
Practice Address - Phone:781-934-7292
Practice Address - Fax:781-934-8112
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67566OtherBLUE CROSS
MAJEY68071Medicare ID - Type Unspecified