Provider Demographics
NPI:1609424787
Name:WING, JENNA (MS,LAT,ATC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WING
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 36TH AVE S APT 103
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7171
Mailing Address - Country:US
Mailing Address - Phone:224-226-1448
Mailing Address - Fax:
Practice Address - Street 1:1425 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4039
Practice Address - Country:US
Practice Address - Phone:701-746-8374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer