Provider Demographics
NPI:1669597324
Name:JENSEN, KATHERYN S (PT)
Entity type:Individual
Prefix:
First Name:KATHERYN
Middle Name:S
Last Name:JENSEN
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 1:3541 PLOVER RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-2155
Mailing Address - Country:US
Mailing Address - Phone:715-423-5423
Mailing Address - Fax:715-423-1532
Practice Address - Street 1:3541 PLOVER RD
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-2155
Practice Address - Country:US
Practice Address - Phone:715-423-5423
Practice Address - Fax:715-423-1532
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4362-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40211800Medicaid