=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164975645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSE GARRETT ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2016
-----------------------------------------------------
Last Update Date | 08/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 GRAND AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-325-8656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 GRAND AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-325-8656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MANAGER
-----------------------------------------------------
Name | MR. JESSE MORGAN GARRETT
-----------------------------------------------------
Credential | L. AC.
-----------------------------------------------------
Telephone | 651-325-8656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 1662
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------