=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750755211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN JEANETTE PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2015
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 338 MAIN ST
-----------------------------------------------------
City | KETCHIKAN
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99901-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-247-2473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2417 TONGASS AVE # 111-271
-----------------------------------------------------
City | KETCHIKAN
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99901-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-247-2473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 102770
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------