Basic Information
| Provider Information | |||||||||
| NPI: | 1063869048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEXTER | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 3385 DEXTER CT STE 203 | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528073471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633329312 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2016 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 082725 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.