Healthcare Provider Details

I. General information

NPI: 1992880579
Provider Name (Legal Business Name): JODI ANN MATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 HERITAGE PL STE A
FARIBAULT MN
55021-5251
US

IV. Provider business mailing address

328 HERITAGE PL STE A
FARIBAULT MN
55021-5251
US

V. Phone/Fax

Practice location:
  • Phone: 507-332-0202
  • Fax: 507-332-2206
Mailing address:
  • Phone: 507-332-0202
  • Fax: 507-332-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: