Healthcare Provider Details

I. General information

NPI: 1366442915
Provider Name (Legal Business Name): CONNIE JENSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8209 WATSON ST SUITE 100
MC LEAN VA
22102-4402
US

IV. Provider business mailing address

9900 MAIN ST SUITE 200A
FAIRFAX VA
22031-3907
US

V. Phone/Fax

Practice location:
  • Phone: 703-734-2889
  • Fax: 703-734-2139
Mailing address:
  • Phone: 703-279-4394
  • Fax: 703-279-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305001979
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: