Healthcare Provider Details

I. General information

NPI: 1487986634
Provider Name (Legal Business Name): THERESA JENSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

44 FOREST AVE
MASSAPEQUA NY
11758-7807
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4108
  • Fax: 631-376-3281
Mailing address:
  • Phone: 516-795-2582
  • Fax: 631-376-3281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number016287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: