Provider Demographics
NPI:1023123452
Name:JENNINGS, KRISTIN A (PT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:A
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1835 E EDGEWOOD DR STE 10583
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9407
Mailing Address - Country:US
Mailing Address - Phone:920-841-3018
Mailing Address - Fax:
Practice Address - Street 1:N1287 LAUDON LN
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944-9382
Practice Address - Country:US
Practice Address - Phone:920-841-3018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4020-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40471900Medicaid
WI001586015Medicare ID - Type Unspecified
WI40471900Medicaid