Provider Demographics
NPI:1215133715
Name:ETCHISON, JENNIFFER GAITE (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFFER
Middle Name:GAITE
Last Name:ETCHISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFFER
Other - Middle Name:
Other - Last Name:GAITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8905 DUNMORE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3449
Mailing Address - Country:US
Mailing Address - Phone:260-804-7819
Mailing Address - Fax:
Practice Address - Street 1:8905 DUNMORE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-3449
Practice Address - Country:US
Practice Address - Phone:260-804-7819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008583A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist