Provider Demographics
NPI:1588855845
Name:HANSEN, JEREMY SCOTT (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PT, DPT
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 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:2045 BROADWATER AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4863
Practice Address - Country:US
Practice Address - Phone:406-656-0950
Practice Address - Fax:406-656-0970
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9700225100000X
CA34755225100000X
MTPTP-PT-LIC-7940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU763YMedicare PIN
CABU763ZMedicare PIN
MTM011006280Medicare PIN