Provider Demographics
NPI:1174881882
Name:JENSEN, KAITLYN (LAT, PTA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LAT, PTA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9138
Mailing Address - Country:US
Mailing Address - Phone:715-822-6167
Mailing Address - Fax:715-822-6142
Practice Address - Street 1:1110 7TH AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9138
Practice Address - Country:US
Practice Address - Phone:715-822-6167
Practice Address - Fax:715-822-6142
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2856-19225200000X
WI1260-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant