Healthcare Provider Details

I. General information

NPI: 1477614733
Provider Name (Legal Business Name): ANN VICTORIA JORSTAD PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIS CLINIC PSC 482 BOX 1600
FPO AP
96367
JP

IV. Provider business mailing address

2213 HIDDEN VALLEY RD
NORTHFIELD MN
55057-3109
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-2747
  • Fax:
Mailing address:
  • Phone: 507-663-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1096
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: