Provider Demographics
NPI:1821219585
Name:LIST, JENNA DANIELLE (MSPT)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:DANIELLE
Last Name:LIST
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:DANIELLE
Other - Last Name:PEITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2472 PATTERSON RD UNIT 9
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1100
Mailing Address - Country:US
Mailing Address - Phone:970-245-0511
Mailing Address - Fax:
Practice Address - Street 1:2472 PATTERSON RD UNIT 9
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1100
Practice Address - Country:US
Practice Address - Phone:970-245-0511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011483225100000X
COPTL.12922225100000X
OHPT10373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2308185Medicaid
OH341952632-00OtherWORKERS COMP
OH341952632-00OtherWORKERS COMP