Provider Demographics
NPI:1770306201
Name:LANDGREN, JENNIFER A (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LANDGREN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1500 MADISON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-6693
Mailing Address - Country:US
Mailing Address - Phone:651-317-9490
Mailing Address - Fax:
Practice Address - Street 1:1500 MADISON AVE STE 210
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-6693
Practice Address - Country:US
Practice Address - Phone:651-317-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14267-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist