Healthcare Provider Details

I. General information

NPI: 1992113203
Provider Name (Legal Business Name): TARA MARIE JAEGER PT, DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 UNIVERSITY DR S
FARGO ND
58104-6225
US

IV. Provider business mailing address

3426 23RD ST S
MOORHEAD MN
56560-5314
US

V. Phone/Fax

Practice location:
  • Phone: 701-412-1873
  • Fax:
Mailing address:
  • Phone: 701-412-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number471-12
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number1993
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1993
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: