Healthcare Provider Details

I. General information

NPI: 1740715069
Provider Name (Legal Business Name): JESSICA ANN BJORLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 9TH AVE
GRANITE FALLS MN
56241-1326
US

IV. Provider business mailing address

418 9TH ST N
BENSON MN
56215-1433
US

V. Phone/Fax

Practice location:
  • Phone: 320-564-4081
  • Fax:
Mailing address:
  • Phone: 320-368-2757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3257
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: