Provider Demographics
NPI:1194154492
Name:LANCASTER, JENNIFER (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANCASTER
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 1:7855 CURRIER DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4314
Mailing Address - Country:US
Mailing Address - Phone:269-323-7748
Mailing Address - Fax:269-323-1908
Practice Address - Street 1:7855 CURRIER DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4314
Practice Address - Country:US
Practice Address - Phone:269-323-7748
Practice Address - Fax:269-323-1908
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002136225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant