Healthcare Provider Details

I. General information

NPI: 1194688226
Provider Name (Legal Business Name): JESSE MORGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 GIRARD AVE N
MINNEAPOLIS MN
55411-2057
US

IV. Provider business mailing address

2410 GIRARD AVE N
MINNEAPOLIS MN
55411-2057
US

V. Phone/Fax

Practice location:
  • Phone: 612-668-2121
  • Fax:
Mailing address:
  • Phone: 612-668-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: