Provider Demographics
NPI:1831217454
Name:FISKE, JENNIFER E (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:FISKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:443 LYNN HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1808
Mailing Address - Country:US
Mailing Address - Phone:314-395-9303
Mailing Address - Fax:314-395-9301
Practice Address - Street 1:17300 N OUTER 40 RD
Practice Address - Street 2:SUITE 205
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-728-1777
Practice Address - Fax:636-728-1793
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005000503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist