Provider Demographics
NPI:1679343776
Name:VON DOELLEN, JENNIE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:
Last Name:VON DOELLEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:1510 W BRANCH ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1817
Practice Address - Country:US
Practice Address - Phone:805-489-7912
Practice Address - Fax:805-489-9697
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist