Provider Demographics
NPI:1841571163
Name:SHOUP, JENNA M (PT)
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:M
Last Name:SHOUP
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 1:131 POMEROY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9331
Mailing Address - Country:US
Mailing Address - Phone:413-262-7727
Mailing Address - Fax:
Practice Address - Street 1:131 POMEROY MEADOW RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01073-9331
Practice Address - Country:US
Practice Address - Phone:413-262-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist