Healthcare Provider Details

I. General information

NPI: 1780848002
Provider Name (Legal Business Name): JENNIFER L CRISP P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MEDICAL PLAZA LANE SUITE A
WHITESBURG KY
41858
US

IV. Provider business mailing address

149 MEDICAL PLAZA LANE SUITE A
WHITESBURG KY
41858
US

V. Phone/Fax

Practice location:
  • Phone: 606-632-1188
  • Fax: 606-632-0075
Mailing address:
  • Phone: 606-632-1188
  • Fax: 606-632-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005300
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: