Provider Demographics
NPI:1265176556
Name:WATHEN, JENNIFER LEE (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WATHEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3227 SOUTTER AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-3149
Mailing Address - Country:US
Mailing Address - Phone:319-929-1252
Mailing Address - Fax:
Practice Address - Street 1:502 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101065225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant