Provider Demographics
NPI:1053640599
Name:HERGENROTHER, JEANNE A (PT)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:A
Last Name:HERGENROTHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1352
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-1352
Mailing Address - Country:US
Mailing Address - Phone:970-731-7474
Mailing Address - Fax:
Practice Address - Street 1:2050 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2407
Practice Address - Country:US
Practice Address - Phone:970-874-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist