Basic Information
| Provider Information | |||||||||
| NPI: | 1700113982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4415 W 36 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4415 W 36 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 03/20/2011 | ||||||||
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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 | 1121507 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 8683 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.