Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 041-0000318 | VT |
NPI | 1003015579 |
---|---|
Provider Name | Ms. Tina Marie Jensen |
First Address | East Wallingford, VT 05742-9690 |
Second Address | Rutland, VT 05701-4832 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2007 |
Last Update Date | 15/07/2007 |