Basic Information
| Provider Information | |||||||||
| NPI: | 1306045661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'BRIEN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 BROADWAY RD | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060711716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133066687 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 464 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010011826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133066687 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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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 | 225200000X | 8137 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.