Healthcare Provider Details

I. General information

NPI: 1629382619
Provider Name (Legal Business Name): JENNA MARIE BAIN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S MAIN ST STE A
LAMOURE ND
58458-7412
US

IV. Provider business mailing address

16 S MAIN ST
LAMOURE ND
58458-7412
US

V. Phone/Fax

Practice location:
  • Phone: 701-883-5611
  • Fax:
Mailing address:
  • Phone: 701-883-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60161010
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1949
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1668
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: