Provider Demographics
NPI:1063869048
Name:BUSH, JENNA M (DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:WEXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:3385 DEXTER CT STE 203
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-332-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082725225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist