Provider Demographics
NPI:1174927420
Name:ANDERSON, JENNIFER ROSE (ATC)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ROSE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18952 E FISHER RD
Mailing Address - Street 2:
Mailing Address - City:ST MARYS CITY
Mailing Address - State:MD
Mailing Address - Zip Code:20686-3002
Mailing Address - Country:US
Mailing Address - Phone:240-895-2135
Mailing Address - Fax:
Practice Address - Street 1:18952 E FISHER RD
Practice Address - Street 2:
Practice Address - City:ST MARYS CITY
Practice Address - State:MD
Practice Address - Zip Code:20686-3002
Practice Address - Country:US
Practice Address - Phone:240-895-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA006692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer