Basic Information
| Provider Information | |||||||||
| NPI: | 1902373475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAU | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | OSCAR | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1266727422 | ||||||||
| FaxNumber: | 6126768992 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | 6126768992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 105817 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 105817 | 01 | MN | MINNESOTA BOARD OF OCCUPATIONAL THERAPY LICENSE | OTHER |