Provider Demographics
NPI:1740580190
Name:PUTT, JENNIFER J (MPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:PUTT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 DUFOUR ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5915
Mailing Address - Country:US
Mailing Address - Phone:831-227-4331
Mailing Address - Fax:
Practice Address - Street 1:15 PENNY LN
Practice Address - Street 2:SUITE 4
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6010
Practice Address - Country:US
Practice Address - Phone:831-724-8235
Practice Address - Fax:831-724-9099
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP932Medicare PIN
CAEN580XMedicare PIN