Provider Demographics
NPI:1669707030
Name:HANSON, JENNIFER R (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:HANSON
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 1:825 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1675
Mailing Address - Country:US
Mailing Address - Phone:920-623-2520
Mailing Address - Fax:
Practice Address - Street 1:825 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1675
Practice Address - Country:US
Practice Address - Phone:920-623-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11075-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist