Healthcare Provider Details

I. General information

NPI: 1508230459
Provider Name (Legal Business Name): JENNIFER EHLE P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 EMBASSY WEST DR
DUBUQUE IA
52002-2276
US

IV. Provider business mailing address

350 N GRANDVIEW AVE
DUBUQUE IA
52001-6388
US

V. Phone/Fax

Practice location:
  • Phone: 563-585-1290
  • Fax:
Mailing address:
  • Phone: 563-582-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number078255
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: