=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487734190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER R KRAVITZ PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 S MAIN ST GREEN MOUNTAIN PHYSICAL THERAPY LNC
-----------------------------------------------------
City | W LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-298-5595
-----------------------------------------------------
Fax | 603-298-5205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 DOTHAN ST
-----------------------------------------------------
City | WHITE RIVER JUNCTION
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-295-6350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | NH0662
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------