Healthcare Provider Details

I. General information

NPI: 1821926155
Provider Name (Legal Business Name): MR. JACOB MICHAEL ENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 MAGNOLIA ST NW
COON RAPIDS MN
55448-3227
US

IV. Provider business mailing address

11400 MAGNOLIA ST NW
COON RAPIDS MN
55448-3227
US

V. Phone/Fax

Practice location:
  • Phone: 763-433-4933
  • Fax:
Mailing address:
  • Phone: 763-433-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14476841
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: