Provider Demographics
NPI:1538517966
Name:WAGES, JENSEN HACKETT (DPT)
Entity Type:Individual
Prefix:
First Name:JENSEN
Middle Name:HACKETT
Last Name:WAGES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PEARL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-7509
Mailing Address - Country:US
Mailing Address - Phone:706-638-3880
Mailing Address - Fax:706-638-3890
Practice Address - Street 1:106 PEARL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7509
Practice Address - Country:US
Practice Address - Phone:706-638-3880
Practice Address - Fax:706-638-3890
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I653421Medicare PIN