Provider Demographics
NPI:1699088542
Name:SWANSON, JENNA (DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 JUDD PLACE DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2386
Mailing Address - Country:US
Mailing Address - Phone:919-557-8305
Mailing Address - Fax:919-578-8780
Practice Address - Street 1:304 JUDD PLACE DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2386
Practice Address - Country:US
Practice Address - Phone:919-557-8305
Practice Address - Fax:919-578-8780
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212790Medicaid
NC7212790Medicaid