Basic Information
| Provider Information | |||||||||
| NPI: | 1215162565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORVARI-HEDLUND | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 W SUPERIOR ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558061885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187271180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 W SUPERIOR ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558061885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187271180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11235-024 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10973 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1215162565 | 05 | WI | MEDICAID |