Provider Demographics
NPI:1679971659
Name:DORMAN, JENNIFER (ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DORMAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6286 BRIARCREST AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4023
Mailing Address - Country:US
Mailing Address - Phone:901-237-3301
Mailing Address - Fax:
Practice Address - Street 1:7600 MACON RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4900
Practice Address - Country:US
Practice Address - Phone:901-754-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000017522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer