Provider Demographics
NPI:1710962261
Name:NOEL, JENNIFER LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:NOEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:REISENAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:256 SKYVIEW LN
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-9559
Mailing Address - Country:US
Mailing Address - Phone:406-560-1552
Mailing Address - Fax:406-846-1347
Practice Address - Street 1:1100 HOLLENBECK LN
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-2317
Practice Address - Country:US
Practice Address - Phone:406-846-1991
Practice Address - Fax:406-846-1347
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-2335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8432338Medicaid
WA8855331Medicare PIN