Provider Demographics
NPI:1528481736
Name:KIBBON, JENNA (PT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KIBBON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:WOODFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2700 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5604
Practice Address - Country:US
Practice Address - Phone:307-634-7986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1519225100000X
NE2336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist