Healthcare Provider Details

I. General information

NPI: 1568138576
Provider Name (Legal Business Name): JACOB E TODD PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CENTRAL AVE W STE 102
SAINT MICHAEL MN
55376-9711
US

IV. Provider business mailing address

1939 MINNEHAHA AVE W STE 300
SAINT PAUL MN
55104-1033
US

V. Phone/Fax

Practice location:
  • Phone: 763-595-1300
  • Fax: 763-276-1190
Mailing address:
  • Phone: 651-748-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-7512
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14353
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: