Healthcare Provider Details

I. General information

NPI: 1992940845
Provider Name (Legal Business Name): JEAN MARIE CARLSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2008
Last Update Date: 12/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7511 FOXWOOD DR
SCHERERVILLE IN
46375-3359
US

IV. Provider business mailing address

7511 FOXWOOD DR
SCHERERVILLE IN
46375-3359
US

V. Phone/Fax

Practice location:
  • Phone: 219-864-5924
  • Fax: 219-864-5924
Mailing address:
  • Phone: 219-864-5924
  • Fax: 219-864-5924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number05002793A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number05002793A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: