Basic Information
| Provider Information | |||||||||
| NPI: | 1912292871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNER | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1377 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416963473 | ||||||||
| FaxNumber: | 5416363480 | ||||||||
| Practice Location | |||||||||
| Address1: | 598 E 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974014267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416363473 | ||||||||
| FaxNumber: | 5416363480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4963 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.