MEDICARE: LEILA MARIE JENSEN PTA, LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2150058	TX
2	225700000X	Massage Therapist	MT127712	TX

General Provider Information

NPI Number	:	1205485851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEILA MARIE JENSEN PTA, LMT

Provider Business Mailing Address
First Line	:	1318 KALLIE HILLS LN
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-3755
Country	:	US
Telephone Number	:	281-757-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	14405 WALTERS RD STE 1017
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77014-1337
Country	:	US
Telephone Number	:	281-781-8283
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2019
Last Update Date	:	09/06/2019

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