Healthcare Provider Details

I. General information

NPI: 1144909433
Provider Name (Legal Business Name): JEREMY BRUNNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 GALTIER ST
SAINT PAUL MN
55103-2358
US

IV. Provider business mailing address

1219 10TH ST NW APT 105
NEW BRIGHTON MN
55112-6787
US

V. Phone/Fax

Practice location:
  • Phone: 651-224-1848
  • Fax:
Mailing address:
  • Phone: 651-353-8828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2480
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: