Provider Demographics
NPI:1003015579
Name:JENSEN, TINA MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:EAST WALLINGFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05742-9690
Mailing Address - Country:US
Mailing Address - Phone:802-259-2192
Mailing Address - Fax:
Practice Address - Street 1:9 HAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4832
Practice Address - Country:US
Practice Address - Phone:802-747-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041-0000318225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant