Provider Demographics
NPI:1588831770
Name:HANSEN, JENNIFER ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:ADAMSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2050 SANDALWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1947
Mailing Address - Country:US
Mailing Address - Phone:920-265-4862
Mailing Address - Fax:
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-265-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6291-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588831770Medicaid