Provider Demographics
NPI:1659307031
Name:NICEWANNER, JENNIFER S (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:NICEWANNER
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 1:250 12TH AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2911
Mailing Address - Country:US
Mailing Address - Phone:319-354-4800
Mailing Address - Fax:319-354-4819
Practice Address - Street 1:250 12TH AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2911
Practice Address - Country:US
Practice Address - Phone:319-354-4800
Practice Address - Fax:319-354-4819
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPT1100222251X0800X
IA072167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO221554873Medicare PIN
IAIB1212037Medicare PIN
IAIB1212Medicare PIN