=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770063216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LEEANN BANKS DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2018
-----------------------------------------------------
Last Update Date | 08/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64-974 MAMALAHOA HWY STE 103
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-7334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-887-1371
-----------------------------------------------------
Fax | 808-887-1373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1374 COUGAR DR
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59718-8380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-599-1649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 14914
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------