Basic Information
| Provider Information | |||||||||
| NPI: | 1518211697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEARSON | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 S SR 49 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463839790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193095461 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 CUMBERLAND XING | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192863890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12214-24 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT.014010 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05011733A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 714850269 | 05 | IN | MEDICAID |