Provider Demographics
NPI:1386797728
Name:JENNINGS, KATHY (PT)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6316 CONSTITUTION AVE NE
Mailing Address - Street 2:MARK TWAIN ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5944
Mailing Address - Country:US
Mailing Address - Phone:505-255-8337
Mailing Address - Fax:
Practice Address - Street 1:6316 CONSTITUTION AVE NE
Practice Address - Street 2:MARK TWAIN ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5944
Practice Address - Country:US
Practice Address - Phone:505-255-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB 7106Medicaid