1174506802 NPI number — TIFFANY LYNN JENSON MPT ATC

Table of content: (NPI 1528298486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174506802 NPI number — TIFFANY LYNN JENSON MPT ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSON
Provider First Name:
TIFFANY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174506802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-0421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-747-2455
Provider Business Mailing Address Fax Number:
509-227-7070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 N WASHINGTON ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-568-3900
Provider Business Practice Location Address Fax Number:
509-568-3938
Provider Enumeration Date:
11/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT7880 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00007880 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2078120 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7080112 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134891 . This is a "L AND I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1174506802 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01782560 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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