Provider Demographics
NPI:1942235726
Name:HENRIKSEN, JENNIFER TANNER (MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TANNER
Last Name:HENRIKSEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:7525 N CEDAR AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2689
Mailing Address - Country:US
Mailing Address - Phone:559-257-3991
Mailing Address - Fax:559-257-3992
Practice Address - Street 1:7525 N CEDAR AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-257-3991
Practice Address - Fax:559-257-3992
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297376225100000X
WAPT60277353225100000X
OR5020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1942235726Medicaid
WA0302887OtherDEPT. OF LABOR AND INDUSTRIES
ORR134567Medicare PIN
WAG8914949Medicare PIN
WA0302887OtherDEPT. OF LABOR AND INDUSTRIES
ORQ50042Medicare UPIN