1710261052 NPI number — MRS. JENNIFER H BROSSART PT

Table of content: MRS. JENNIFER H BROSSART PT (NPI 1710261052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710261052 NPI number — MRS. JENNIFER H BROSSART PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROSSART
Provider First Name:
JENNIFER
Provider Middle Name:
H
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUNDE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT/LATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710261052
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2975 HIGHWAY 2E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUGBY
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-776-5261
Provider Business Mailing Address Fax Number:
701-776-5448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2975 HIGHWAY 2E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUGBY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-776-5261
Provider Business Practice Location Address Fax Number:
701-776-5448
Provider Enumeration Date:
10/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1266 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54539 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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