Provider Demographics
NPI:1184390643
Name:STANSHAW-BASA, JENNIFER (ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STANSHAW-BASA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STANSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:5080 SPECTRUM DR STE 1200W
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4624
Mailing Address - Country:US
Mailing Address - Phone:469-261-4337
Mailing Address - Fax:
Practice Address - Street 1:5199 IVY ST
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-4404
Practice Address - Country:US
Practice Address - Phone:800-289-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000001852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer