Provider Demographics
NPI:1477897932
Name:COLGROVE, JENNIFER J (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:COLGROVE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:SQUIRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4110 S 144TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1013
Mailing Address - Country:US
Mailing Address - Phone:402-861-6683
Mailing Address - Fax:402-861-6689
Practice Address - Street 1:4110 S 144TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1013
Practice Address - Country:US
Practice Address - Phone:402-861-6683
Practice Address - Fax:402-861-6689
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEPENDINGMedicaid
NE098958Medicare PIN