Provider Demographics
NPI:1255567434
Name:KANIESKI, JENNIFER LYN (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:KANIESKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYN
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8201 GOLF COURSE RD NW # D3-178
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5842
Mailing Address - Country:US
Mailing Address - Phone:928-460-3599
Mailing Address - Fax:
Practice Address - Street 1:10301 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5380
Practice Address - Country:US
Practice Address - Phone:928-460-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4499225100000X
NM3863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3863OtherNEW MEXICO BOARD OF PHYSICAL THERAPY
OR4499OtherOREGON LICENSE
ORPENDINGMedicaid