Basic Information
| Provider Information | |||||||||
| NPI: | 1770599821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKLITCH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3111 124TH AVE NW STE 123 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554334573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632368955 | ||||||||
| FaxNumber: | 6372368966 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT ST NW STE 405 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632360888 | ||||||||
| FaxNumber: | 7632360885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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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 | 7039 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 64-03344 | 01 | MN | MEDICA | OTHER | HP43276 | 01 | MN | HEALTHPARTNERS | OTHER | 245J4NO | 01 | MN | BCBS - MINNESOTA | OTHER |