Provider Demographics
NPI:1285909796
Name:CHANG, JENNIFER MALLORY (PT, DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MALLORY
Last Name:CHANG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MALLORY
Other - Last Name:YORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:3140 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2108
Practice Address - Country:US
Practice Address - Phone:760-720-9898
Practice Address - Fax:760-720-1636
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist