Provider Demographics
NPI:1871002469
Name:MAGSAM, JENNA LAMAY
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LAMAY
Last Name:MAGSAM
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 1:2825 WOODLANE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2906
Mailing Address - Country:US
Mailing Address - Phone:651-202-0222
Mailing Address - Fax:
Practice Address - Street 1:1130 N WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-3217
Practice Address - Country:US
Practice Address - Phone:928-233-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2650-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant