Basic Information
| Provider Information | |||||||||
| NPI: | 1538773601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAQUETTE | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | ALINA HEALTH | ||||||||
| Address2: | 8100 WEST 78TH STREET, SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
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| Practice Location | |||||||||
| Address1: | ALINA HEALTH | ||||||||
| Address2: | 8100 WEST 78TH STREET, SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2383 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.