Basic Information
Provider Information | |||||||||
NPI: | 1619529195 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORRESTER | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11 DANBEN CT | ||||||||
Address2: |   | ||||||||
City: | NOTTINGHAM | ||||||||
State: | MD | ||||||||
PostalCode: | 212362426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107079498 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2420 N SALISBURY BLVD UNIT 5 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218012189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105464952 | ||||||||
FaxNumber: | 4105468358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2019 | ||||||||
LastUpdateDate: | 07/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT027666 | PA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 22692 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.