MEDICARE: MRS. JENNIFER LYN SHEAN PTA

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	225200000X	Physical Therapy Assistant	3535	NC
2	225200000X	Physical Therapy Assistant	2005037324	MO
3	225200000X	Physical Therapy Assistant	006135	NY

General Provider Information

NPI Number	:	1962528364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER LYN SHEAN PTA

Provider Business Mailing Address
First Line	:	10 NORMANDY DR
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28307-3479
Country	:	US
Telephone Number	:	845-537-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 ANN ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5543
Country	:	US
Telephone Number	:	910-484-7660
Fax Number	:

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/08/2007

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