Provider Demographics
NPI:1912963398
Name:FUNKE, JENNIFER G (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:FUNKE
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:PO BOX 1064
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1064
Mailing Address - Country:US
Mailing Address - Phone:573-778-9348
Mailing Address - Fax:573-686-0178
Practice Address - Street 1:3381 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3060
Practice Address - Country:US
Practice Address - Phone:573-775-0761
Practice Address - Fax:573-785-0031
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003022299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO486083702Medicaid
MO216821706Medicare ID - Type Unspecified