=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457769713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER L MOLTZ PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2014
-----------------------------------------------------
Last Update Date | 07/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 SAN REMO DR
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-865-0010
-----------------------------------------------------
Fax | 802-865-0050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 SAN REMO DR
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-865-0010
-----------------------------------------------------
Fax | 802-865-0050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 040.0102690
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------