Provider Demographics
NPI:1093133316
Name:BAN, JENNIFER (PTA, CMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAN
Suffix:
Gender:F
Credentials:PTA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 CANYON BLVD STE A4
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6727
Mailing Address - Country:US
Mailing Address - Phone:303-304-1054
Mailing Address - Fax:
Practice Address - Street 1:2660 CANYON BLVD STE A4
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6727
Practice Address - Country:US
Practice Address - Phone:303-304-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013258225200000X
VACP024755A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant