Provider Demographics
NPI:1104067834
Name:SIMPSON, JENNIFER ANN (LMT, IANMT, CFT/CMT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:LMT, IANMT, CFT/CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-2840
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000675172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582478355Medicaid
GA582478355Medicaid