MEDICARE: MADISON RAE JENSEN PTA

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	1850	NE

General Provider Information

NPI Number	:	1437754736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON RAE JENSEN PTA

Provider Business Mailing Address
First Line	:	2501 N 61ST ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68104-4017
Country	:	US
Telephone Number	:	402-686-9689
Fax Number	:

Provider Business Practice Location Address
First Line	:	2824 N 66TH AVE # NE68104
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68104-3928
Country	:	US
Telephone Number	:	402-551-2110
Fax Number	:

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

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	12/03/2020

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