Healthcare Provider Details

I. General information

NPI: 1053615559
Provider Name (Legal Business Name): JLA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2010
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-3041
US

IV. Provider business mailing address

2535 PARK AVE
MINNEAPOLIS MN
55404-4404
US

V. Phone/Fax

Practice location:
  • Phone: 612-799-7982
  • Fax:
Mailing address:
  • Phone: 612-799-7982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5074
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number855
License Number StateMN

VIII. Authorized Official

Name: DR. JONATHAN LEE ARNOLD
Title or Position: OWNER
Credential: D.C.
Phone: 612-799-7982