Healthcare Provider Details

I. General information

NPI: 1538517966
Provider Name (Legal Business Name): JENSEN HACKETT WAGES DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 PEARL DR SUITE 104
LA FAYETTE GA
30728-7509
US

IV. Provider business mailing address

106 PEARL DR SUITE 104
LA FAYETTE GA
30728-7509
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-3880
  • Fax: 706-638-3890
Mailing address:
  • Phone: 706-638-3880
  • Fax: 706-638-3890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: