Provider Demographics
NPI:1790428605
Name:ROBERTSON, JENNA PAIGE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:PAIGE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:3385 DEXTER CT STE 301
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-344-6645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist