Provider Demographics
NPI:1801292297
Name:STIDHAM, JENNIFER L
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1171 W TIPTON ST
Mailing Address - Street 2:SUITE L
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2793
Mailing Address - Country:US
Mailing Address - Phone:812-522-7007
Mailing Address - Fax:812-522-7043
Practice Address - Street 1:1171 W TIPTON ST
Practice Address - Street 2:SUITE L
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2793
Practice Address - Country:US
Practice Address - Phone:812-522-7007
Practice Address - Fax:812-522-7043
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004747A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist