Provider Demographics
NPI:1316306855
Name:SANDBERG, JENNIFER (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SANDBERG
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 1:11020 S COUNTY ROAD 600 W
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47334-9442
Mailing Address - Country:US
Mailing Address - Phone:765-748-1634
Mailing Address - Fax:
Practice Address - Street 1:11020 S COUNTY ROAD 600 W
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:IN
Practice Address - Zip Code:47334-9442
Practice Address - Country:US
Practice Address - Phone:765-748-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004810A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant