Provider Demographics
NPI:1912930520
Name:DESORMIER, JENNA (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DESORMIER
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11817 RIDGE PKWY
Mailing Address - Street 2:1034
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-5083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 W 84TH AVE
Practice Address - Street 2:SUITE 152
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-4810
Practice Address - Country:US
Practice Address - Phone:303-426-0967
Practice Address - Fax:303-426-4241
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist