Healthcare Provider Details

I. General information

NPI: 1124389713
Provider Name (Legal Business Name): RUSSELL J JENSEN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 FAIRGROUND AVE
HIGGINSVILLE MO
64037-1638
US

IV. Provider business mailing address

720 FAIRGROUND AVE
HIGGINSVILLE MO
64037-1638
US

V. Phone/Fax

Practice location:
  • Phone: 660-584-7801
  • Fax: 660-584-8619
Mailing address:
  • Phone: 660-584-7801
  • Fax: 660-584-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117234
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: