Provider Demographics
NPI:1245060318
Name:PHELPS, JENNIFER LYNN (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CONCORD CIR
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1419
Mailing Address - Country:US
Mailing Address - Phone:781-953-1873
Mailing Address - Fax:
Practice Address - Street 1:7 CONCORD CIR
Practice Address - Street 2:
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1419
Practice Address - Country:US
Practice Address - Phone:781-953-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2699225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant