Provider Demographics
NPI:1063888113
Name:STAVENGER, JENNIFER (ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STAVENGER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SANDQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3909 E BROOKLINE DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-5702
Mailing Address - Country:US
Mailing Address - Phone:605-360-6135
Mailing Address - Fax:
Practice Address - Street 1:3909 E BROOKLINE DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-5702
Practice Address - Country:US
Practice Address - Phone:605-360-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD03152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer