Provider Demographics
NPI:1508559808
Name:LARUE, JENNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:LARUE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6156 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1913
Mailing Address - Country:US
Mailing Address - Phone:937-776-3412
Mailing Address - Fax:
Practice Address - Street 1:6465 E BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1576
Practice Address - Country:US
Practice Address - Phone:614-864-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist