Healthcare Provider Details

I. General information

NPI: 1487880910
Provider Name (Legal Business Name): KELSIE LEE JANSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6385 RIDGELINE DR UNIT C
COLD SPRING KY
41076-9310
US

IV. Provider business mailing address

6385 RIDGELINE DR APT C
COLD SPRING KY
41076
US

V. Phone/Fax

Practice location:
  • Phone: 513-612-0969
  • Fax:
Mailing address:
  • Phone: 513-612-0969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02461
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA. 07043
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: