Provider Demographics
NPI:1629382619
Name:BAIN, JENNA MARIE (PT)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:BAIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58458-7412
Mailing Address - Country:US
Mailing Address - Phone:701-883-5611
Mailing Address - Fax:
Practice Address - Street 1:16 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LAMOURE
Practice Address - State:ND
Practice Address - Zip Code:58458-7412
Practice Address - Country:US
Practice Address - Phone:701-883-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60161010225100000X
ND1949225100000X
SD1668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist