Basic Information
| Provider Information | |||||||||
| NPI: | 1033575493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIBBS | ||||||||
| FirstName: | JENNETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
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| OtherLastName: | HIBBS | ||||||||
| OtherFirstName: | JENNE | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 OAK KNOLL DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704050742 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 CHARLEVOIX DR SE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883258064 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2016 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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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 | PT-1614 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.