Basic Information
| Provider Information | |||||||||
| NPI: | 1598839557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WETZEL | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 586 LONE TREE DR | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294641390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438847880 | ||||||||
| FaxNumber: | 8438846633 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 JOHNNIE DODDS BLVD # A | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438847880 | ||||||||
| FaxNumber: | 8438846635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5299 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TH1742 | 05 | SC | MEDICAID | GP1753 | 05 | SC | MEDICAID |