Basic Information
| Provider Information | |||||||||
| NPI: | 1528732724 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PULISIC | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 N WASHINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230051623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047981112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2021 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 2305003363 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.