Healthcare Provider Details

I. General information

NPI: 1962079681
Provider Name (Legal Business Name): JENNA ROTTEGER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA KLYNSTRA

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MERIDIAN CROSSINGS STE 240
OKEMOS MI
48864-4586
US

IV. Provider business mailing address

3536 MERIDIAN CROSSINGS STE 240
OKEMOS MI
48864-4586
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-2495
  • Fax:
Mailing address:
  • Phone: 517-347-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-31815
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: