1750755211 NPI number — MS. LAUREN JEANETTE PT, DPT

Table of content: KATHRYN VERDEROSA (NPI 1891409140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750755211 NPI number — MS. LAUREN JEANETTE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEANETTE
Provider First Name:
LAUREN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
LAUREN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750755211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2417 TONGASS AVE # 111-271
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETCHIKAN
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99901-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-247-2473
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
338 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHIKAN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99901-6430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-247-2473
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2015

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:  102770 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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