Provider Demographics
NPI:1891237418
Name:KIENZLE, JILL ELIZABETH (LAT, ATC, MPA)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ELIZABETH
Last Name:KIENZLE
Suffix:
Gender:F
Credentials:LAT, ATC, MPA
Other - Prefix:MISS
Other - First Name:JILL
Other - Middle Name:ELIZABETH
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC, MPA
Mailing Address - Street 1:1307 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:IA
Mailing Address - Zip Code:52342-2307
Mailing Address - Country:US
Mailing Address - Phone:641-484-5253
Mailing Address - Fax:641-484-5312
Practice Address - Street 1:1307 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2307
Practice Address - Country:US
Practice Address - Phone:641-484-5253
Practice Address - Fax:641-484-5312
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer