Healthcare Provider Details

I. General information

NPI: 1972098846
Provider Name (Legal Business Name): JENNIFER CAROLE KIENSTRA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 06/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LOVE LN
SOUTH DENNIS MA
02660-3445
US

IV. Provider business mailing address

1894 37TH ST SE
SAINT CLOUD MN
56304-9508
US

V. Phone/Fax

Practice location:
  • Phone: 508-385-6034
  • Fax:
Mailing address:
  • Phone: 320-227-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23520
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: