Healthcare Provider Details

I. General information

NPI: 1366362600
Provider Name (Legal Business Name): SARA JO BAKKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 COUNTY ROAD F E
WHITE BEAR LAKE MN
55110-3935
US

IV. Provider business mailing address

2731 MACKUBIN ST APT 33
ROSEVILLE MN
55113-2376
US

V. Phone/Fax

Practice location:
  • Phone: 612-750-0428
  • Fax:
Mailing address:
  • Phone: 612-750-0428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: