MEDICARE: MRS. JENNA DANIELLE LIST MSPT

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	225100000X	Physical Therapist	5501011483	MI
2	225100000X	Physical Therapist	PTL.12922	CO
3	225100000X	Physical Therapist	PT10373	OH

General Provider Information

NPI Number	:	1821219585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNA DANIELLE LIST MSPT

Provider Business Mailing Address
First Line	:	2472 PATTERSON RD UNIT 9
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-1100
Country	:	US
Telephone Number	:	970-245-0511
Fax Number	:

Provider Business Practice Location Address
First Line	:	2472 PATTERSON RD UNIT 9
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-1100
Country	:	US
Telephone Number	:	970-245-0511
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	05/17/2024

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