Provider Demographics
NPI:1215567367
Name:KOCUR, JENA
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:KOCUR
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 1:508 LONESOME PINE TRL
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-5478
Mailing Address - Country:US
Mailing Address - Phone:651-242-2702
Mailing Address - Fax:
Practice Address - Street 1:1687 WOODLANE DR STE 201
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3062
Practice Address - Country:US
Practice Address - Phone:651-621-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist