Provider Demographics
NPI:1215403175
Name:JENNER, JULIE RAE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:RAE
Last Name:JENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 CANAL AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2864
Mailing Address - Country:US
Mailing Address - Phone:469-644-4467
Mailing Address - Fax:
Practice Address - Street 1:550 E 3RD AVE APT 104
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-4101
Practice Address - Country:US
Practice Address - Phone:469-644-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015941225100000X
IDPT-7471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist