Healthcare Provider Details

I. General information

NPI: 1417914805
Provider Name (Legal Business Name): JOSEPH JOHN JERKOVICH BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 WAITE AVE S
SAINT CLOUD MN
56301-7336
US

IV. Provider business mailing address

437 31ST AVE N
SAINT CLOUD MN
56303-3760
US

V. Phone/Fax

Practice location:
  • Phone: 320-257-5210
  • Fax:
Mailing address:
  • Phone: 320-252-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2026
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: