Provider Demographics
NPI:1679190391
Name:JESSEN, KATE (PT)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:JESSEN
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 1:123 N WASHINGTON ST UNIT 43
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-5547
Mailing Address - Country:US
Mailing Address - Phone:720-276-1051
Mailing Address - Fax:
Practice Address - Street 1:4350 E RAY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-4703
Practice Address - Country:US
Practice Address - Phone:480-704-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017013225100000X
AZLPT-31345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist