=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487986634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA JENSEN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2010
-----------------------------------------------------
Last Update Date | 02/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-376-4108
-----------------------------------------------------
Fax | 631-376-3281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 FOREST AVE
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758-7807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-795-2582
-----------------------------------------------------
Fax | 631-376-3281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 016287
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------