Provider Demographics
NPI:1861719841
Name:FETTERMAN, JENNIFER REBECCA (PT, DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:FETTERMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:REBECCA
Other - Last Name:ALBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:171 INTREPID LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2548
Mailing Address - Country:US
Mailing Address - Phone:315-437-4689
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354590Medicaid
330241Medicare UPIN