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General NPI Number Information
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NPI Number | 1194248468
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Entity Type | Individual
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Provider Name | JEANNINE MARIE SIMMONS PTA
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Gender | Female
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Dates
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Enumeration Date | 07/19/2017
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Last Update Date | 07/19/2017
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Provider Practice Location Address
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Address Line | 1810 MINNESOTA BLVD
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City | SAINT CLOUD
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State | MN
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Zip | 56304-2436
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Country | US
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Telephone | 320-252-0010
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Fax |
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Provider Business Mailing Address
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Address Line | 1641 KENABEC ST
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City | BIG LAKE
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State | MN
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Zip | 55309-9412
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Country | US
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Telephone | 763-291-9413
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | A1953
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License Number State | MN
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