Healthcare Provider Details

I. General information

NPI: 1578326112
Provider Name (Legal Business Name): JAQELA SHANICE WRENCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 FELTL RD
MINNETONKA MN
55343-3944
US

IV. Provider business mailing address

14301 EWING AVE S
BURNSVILLE MN
55306-4885
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-0222
  • Fax:
Mailing address:
  • Phone: 952-746-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: