MEDICARE: MRS. JENNIFER SUPP WOOD MSPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT012887-L	PA

General Provider Information

NPI Number	:	1235175522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER SUPP WOOD MSPT, ATC

Provider Business Mailing Address
First Line	:	509 CORINTHIAN AVE
Second Line	:
City	:	HATBORO
State	:	PA
Zip	:	19040-2329
Country	:	US
Telephone Number	:	215-957-9387
Fax Number	:

Provider Business Practice Location Address
First Line	:	444 N YORK RD
Second Line	:
City	:	HATBORO
State	:	PA
Zip	:	19040-2102
Country	:	US
Telephone Number	:	215-444-0400
Fax Number	:	215-444-0332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/08/2007

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