Healthcare Provider Details

I. General information

NPI: 1396150181
Provider Name (Legal Business Name): MRS. JENNIFER MARIE BOELTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 BARRIE RD
EDINA MN
55435-2363
US

IV. Provider business mailing address

PO BOX 27373
GOLDEN VALLEY MN
55427-0373
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-5019
  • Fax:
Mailing address:
  • Phone: 612-710-3411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3179
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: