Healthcare Provider Details

I. General information

NPI: 1962804591
Provider Name (Legal Business Name): JENNIFER IVERSON PT, MPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

2400 32ND AVE S
FARGO ND
58103-5800
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8700
  • Fax: 701-234-7961
Mailing address:
  • Phone: 701-234-8700
  • Fax: 701-234-7961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1257
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: