Provider Demographics
NPI:1972631968
Name:PRIEBE, JANE (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:PRIEBE
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 1:2300 SWAN LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-9708
Mailing Address - Country:US
Mailing Address - Phone:319-334-5155
Mailing Address - Fax:319-334-6166
Practice Address - Street 1:2300 SWAN LAKE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-9708
Practice Address - Country:US
Practice Address - Phone:319-334-5155
Practice Address - Fax:319-334-6166
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665745Medicaid
IA166580Medicare ID - Type UnspecifiedPROVIDER # FOR FACILITY
IA0665745Medicaid