Provider Demographics
NPI:1205107026
Name:BABCOCK, JENESSA LIANNE (PT)
Entity type:Individual
Prefix:
First Name:JENESSA
Middle Name:LIANNE
Last Name:BABCOCK
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 1:301 CAPDEVILLA
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-9611
Mailing Address - Country:US
Mailing Address - Phone:406-370-5815
Mailing Address - Fax:
Practice Address - Street 1:309 SW HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1405
Practice Address - Country:US
Practice Address - Phone:406-829-0728
Practice Address - Fax:406-830-3181
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05640225100000X
ID2510225100000X
MTPTP-PT-LIC-2474225100000X
MT2424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist