Provider Demographics
NPI:1821263369
Name:JENNINGS, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JENNINGS
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 1:5408 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-8912
Mailing Address - Country:US
Mailing Address - Phone:319-752-5745
Mailing Address - Fax:
Practice Address - Street 1:3720 QUEEN CT SW
Practice Address - Street 2:SUITE #1
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4735
Practice Address - Country:US
Practice Address - Phone:319-364-0300
Practice Address - Fax:319-364-4043
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist