Provider Demographics
NPI:1972976454
Name:FLETCHER, JENNIFERLYN (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFERLYN
Middle Name:
Last Name:FLETCHER
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 1:2510 CHARLESTON AVE APT E10
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2524
Mailing Address - Country:US
Mailing Address - Phone:208-869-7973
Mailing Address - Fax:
Practice Address - Street 1:5648 SOUTH ADAMS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-475-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5770435-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant