Healthcare Provider Details

I. General information

NPI: 1811341415
Provider Name (Legal Business Name): JACK BALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 33RD ST N STE 100
OAKDALE MN
55128-3630
US

IV. Provider business mailing address

7400 33RD ST N STE 100
OAKDALE MN
55128-3630
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-9240
  • Fax:
Mailing address:
  • Phone: 651-241-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number68496
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2018039614
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68496
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: