Provider Demographics
NPI:1922399187
Name:BRUURSEMA, JENNIFER M (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BRUURSEMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:BOGNICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:18101 R PLAZA
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1929
Mailing Address - Country:US
Mailing Address - Phone:402-933-8333
Mailing Address - Fax:402-933-4755
Practice Address - Street 1:18101 R PLAZA
Practice Address - Street 2:SUITE 106
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-1929
Practice Address - Country:US
Practice Address - Phone:402-933-8333
Practice Address - Fax:402-933-4755
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025395000Medicaid