Basic Information
| Provider Information | |||||||||
| NPI: | 1366646762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | CHARA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 657 BIRCHWOOD RD | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657062206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172340476 | ||||||||
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| Practice Location | |||||||||
| Address1: | 331 HOSPITAL DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336315 | ||||||||
| FaxNumber: | 4175336320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2003031071 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.