Provider Demographics
NPI:1881871507
Name:FUENTES, JENNIFER BREKKE (PT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:BREKKE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BREKKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:112 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:IA
Mailing Address - Zip Code:52175-1022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7588225100000X
IA004182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist