Provider Demographics
NPI:1720124357
Name:DERHAM, JENNIFER LEE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:DERHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:BERTAGNI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:11453 E REUBEN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-4113
Mailing Address - Country:US
Mailing Address - Phone:425-750-9526
Mailing Address - Fax:
Practice Address - Street 1:7728 204TH ST. NE
Practice Address - Street 2:#A
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-403-8250
Practice Address - Fax:360-403-0917
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7452225100000X
WAPT00010288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA226582OtherL&I
WA8841BEOtherREGENCE
WA8156BEOtherREGENCE
WA8946137OtherL&I CRIME
WA8869473OtherMEDICARE
WA3317BEOtherREGENCE B/S
WA8498560OtherDSHS
WA9788127OtherAETNA
WAP00608949OtherRAILROAD MEDICARE
WA6417BEOtherREGENCE