Healthcare Provider Details

I. General information

NPI: 1710071618
Provider Name (Legal Business Name): JENNIFER DAWN HERTING PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH STREET SE
CEDAR RAPIDS IA
52403
US

IV. Provider business mailing address

202 10TH STREET SE
CEDAR RAPIDS IA
52403
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-8171
  • Fax: 319-363-3172
Mailing address:
  • Phone: 319-363-8171
  • Fax: 319-363-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03555
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0665430
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: