Provider Demographics
NPI:1366497190
Name:JENSON, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JENSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:VAN WETERING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16622 W 159TH ST
Mailing Address - Street 2:STE 503
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8014
Mailing Address - Country:US
Mailing Address - Phone:815-838-5070
Mailing Address - Fax:815-838-5071
Practice Address - Street 1:16622 W 159TH ST
Practice Address - Street 2:STE 503
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8014
Practice Address - Country:US
Practice Address - Phone:815-838-5070
Practice Address - Fax:815-838-5071
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-014044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK31566Medicare PIN
ILK31567Medicare PIN