Healthcare Provider Details

I. General information

NPI: 1639619778
Provider Name (Legal Business Name): JENNIFER POLKE L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 JANE ST
VANDERGRIFT PA
15690-6106
US

IV. Provider business mailing address

1161 JANE ST
VANDERGRIFT PA
15690-6106
US

V. Phone/Fax

Practice location:
  • Phone: 412-498-5163
  • Fax:
Mailing address:
  • Phone: 412-498-5163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number010165
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: