Provider Demographics
NPI:1730236969
Name:KNICKERBOCKER, JENNIFER (PTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:KNICKERBOCKER
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 1:2816 BLOOMFIELD DR
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5108
Mailing Address - Country:US
Mailing Address - Phone:615-794-8088
Mailing Address - Fax:
Practice Address - Street 1:1653 MOORESVILLE HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2005
Practice Address - Country:US
Practice Address - Phone:931-359-4506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN821225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant