Provider Demographics
NPI:1376999052
Name:JENSEN, KAITLYN (MS, ATC, ATR)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MS, ATC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:#300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4185 BRADDOCK TRL
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1575
Practice Address - Country:US
Practice Address - Phone:651-683-6945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer