Provider Demographics
NPI:1447334685
Name:HAUSE, JENNIFER ROSE (MPT, CIMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:HAUSE
Suffix:
Gender:F
Credentials:MPT, CIMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7580 CHARLOTTE HWY
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7801
Mailing Address - Country:US
Mailing Address - Phone:803-578-5662
Mailing Address - Fax:803-548-5635
Practice Address - Street 1:7580 CHARLOTTE HWY
Practice Address - Street 2:SUITE 1100
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7801
Practice Address - Country:US
Practice Address - Phone:803-578-5662
Practice Address - Fax:803-548-5635
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7440OtherSTATE LICENSE
NC079KXOtherBCBS PROVIDER
NC7211645Medicaid
NC079KXOtherBCBS PROVIDER