Provider Demographics
NPI:1962558023
Name:AUDETTE, JENNIFER (MS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AUDETTE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881-1124
Mailing Address - Country:US
Mailing Address - Phone:401-874-5625
Mailing Address - Fax:401-874-5630
Practice Address - Street 1:25 W INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881-1124
Practice Address - Country:US
Practice Address - Phone:401-874-5625
Practice Address - Fax:401-874-5630
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI000728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI64-00196OtherUNITED HEALTH PROVIDER ID
RI7554-9OtherBLUE CROSS PROVIDER ID
RI411530OtherBLUE CHIP PROVIDER ID