Healthcare Provider Details

I. General information

NPI: 1215489448
Provider Name (Legal Business Name): JENNIFER REQUEJO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 49TH AVE N
MINNEAPOLIS MN
55430-3621
US

IV. Provider business mailing address

14670 BRUNSWICK AVE S
SAVAGE MN
55378-2856
US

V. Phone/Fax

Practice location:
  • Phone: 612-607-5807
  • Fax:
Mailing address:
  • Phone: 507-676-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8509
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: