Provider Demographics
NPI:1962561969
Name:KNICKERBOCKER, JEANNINE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:MARIE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials: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 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-287-9249
Practice Address - Street 1:1731 W RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4594
Practice Address - Country:US
Practice Address - Phone:319-833-5900
Practice Address - Fax:319-833-5901
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0744060Medicaid
29208OtherWELLMARK
29208OtherWELLMARK