Provider Demographics
NPI:1639698301
Name:JACKSON, JENNA RENAE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RENAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:RENAE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LAT, ATC
Mailing Address - Street 1:1103 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIAPOLIS
Mailing Address - State:IA
Mailing Address - Zip Code:52637-9437
Mailing Address - Country:US
Mailing Address - Phone:319-931-7037
Mailing Address - Fax:
Practice Address - Street 1:1501 STATE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-3306
Practice Address - Country:US
Practice Address - Phone:507-537-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program