Provider Demographics
NPI:1124389713
Name:JENSEN, RUSSELL J (PTA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 FAIRGROUND AVE
Mailing Address - Street 2:
Mailing Address - City:HIGGINSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64037-1638
Mailing Address - Country:US
Mailing Address - Phone:660-584-7801
Mailing Address - Fax:660-584-8619
Practice Address - Street 1:720 FAIRGROUND AVE
Practice Address - Street 2:
Practice Address - City:HIGGINSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64037-1638
Practice Address - Country:US
Practice Address - Phone:660-584-7801
Practice Address - Fax:660-584-8619
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117234225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant