Provider Demographics
NPI:1720446784
Name:JENSEN, MARISA (PT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
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 1:708 S JEFFERSON WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-3216
Mailing Address - Country:US
Mailing Address - Phone:515-962-9555
Mailing Address - Fax:515-961-0087
Practice Address - Street 1:708 S JEFFERSON WAY
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-3216
Practice Address - Country:US
Practice Address - Phone:515-962-9555
Practice Address - Fax:515-961-0087
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist