Provider Demographics
NPI:1639776602
Name:GROEN, JENNIFER L (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GROEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-1954
Mailing Address - Country:US
Mailing Address - Phone:641-512-5099
Mailing Address - Fax:
Practice Address - Street 1:1037 19TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-6436
Practice Address - Country:US
Practice Address - Phone:641-423-0428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00829225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant