Provider Demographics
NPI:1780351106
Name:JEPSEN, BRYANNA (PTA)
Entity type:Individual
Prefix:
First Name:BRYANNA
Middle Name:
Last Name:JEPSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 BALLARD WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40068-9324
Mailing Address - Country:US
Mailing Address - Phone:502-718-3670
Mailing Address - Fax:
Practice Address - Street 1:8800 SMYRNA PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-2364
Practice Address - Country:US
Practice Address - Phone:502-694-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA04310225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant