Basic Information
| Provider Information | |||||||||
| NPI: | 1093772881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKLITCH | ||||||||
| FirstName: | NATHANYAL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200867 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200867 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7056 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6403628 | 01 | MEDICA | OTHER | 65G73JA | 01 | MN | BCBS | OTHER | HP43214 | 01 | HEALTHPARTNERS | OTHER |