Healthcare Provider Details

I. General information

NPI: 1871046466
Provider Name (Legal Business Name): KELLI ANN JENSEN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N 5TH ST
WEST BRANCH IA
52358-9616
US

IV. Provider business mailing address

203 N 5TH ST
WEST BRANCH IA
52358-9616
US

V. Phone/Fax

Practice location:
  • Phone: 563-212-1541
  • Fax:
Mailing address:
  • Phone: 563-212-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number083106
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: