Provider Demographics
NPI:1821233099
Name:KOSOLA, JENNA L (PT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:KOSOLA
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 1:1455 MAIN ST STE 160
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5561
Mailing Address - Country:US
Mailing Address - Phone:970-674-6514
Mailing Address - Fax:970-674-6598
Practice Address - Street 1:1455 MAIN ST STE 160
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5561
Practice Address - Country:US
Practice Address - Phone:970-674-6514
Practice Address - Fax:970-674-6598
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0010013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29688353Medicaid
CO29688353Medicaid
COC25603Medicare PIN
CO403249YLB8Medicare PIN