Healthcare Provider Details

I. General information

NPI: 1083522577
Provider Name (Legal Business Name): JEREMY MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 LYNDALE AVE S STE 430
RICHFIELD MN
55423-2300
US

IV. Provider business mailing address

12971 ARDROE AVE
ROSEMOUNT MN
55068-4835
US

V. Phone/Fax

Practice location:
  • Phone: 952-285-2840
  • Fax: 952-285-2830
Mailing address:
  • Phone: 320-510-0892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10031
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: