Provider Demographics
NPI:1811353899
Name:BAUDER, JENNIFER ANN (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BAUDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7416 NIGH RD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-1308
Mailing Address - Country:US
Mailing Address - Phone:509-280-9191
Mailing Address - Fax:
Practice Address - Street 1:1221 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-386-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160453764225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant