Provider Demographics
NPI:1871046466
Name:JENSEN, KELLI ANN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:IA
Mailing Address - Zip Code:52358-9616
Mailing Address - Country:US
Mailing Address - Phone:563-212-1541
Mailing Address - Fax:
Practice Address - Street 1:203 N 5TH ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:IA
Practice Address - Zip Code:52358-9616
Practice Address - Country:US
Practice Address - Phone:563-212-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0831062081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine