Healthcare Provider Details

I. General information

NPI: 1396347878
Provider Name (Legal Business Name): JAKE PHILLIP TOEDTER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 HART BLVD STE 10
MONTICELLO MN
55362-8539
US

IV. Provider business mailing address

1107 HART BLVD STE 10
MONTICELLO MN
55362-8539
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-6878
  • Fax:
Mailing address:
  • Phone: 763-295-6878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11949
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: