Basic Information
| Provider Information | |||||||||
| NPI: | 1295932713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLIVICK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1761 COUNTY ROAD 1314 | ||||||||
| Address2: | |||||||||
| City: | BARDWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420239050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706283882 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4747 ALBEN BARKLEY DR | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420016789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702012200 | ||||||||
| FaxNumber: | 2704436211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002869 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.