Healthcare Provider Details

I. General information

NPI: 1518675461
Provider Name (Legal Business Name): JASON DONALD ELLENBECKER OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 VIKINGS CIR
EAGAN MN
55121-1002
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7600
  • Fax: 952-456-7601
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number11811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: