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General NPI Number Information
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NPI Number | 1972659894
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Entity Type | Individual
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Provider Name | JACQUELINE LEE PETERSEN MOREHEAD PHYSICAL THERAPY
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Gender | Female
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 401 PHALEN BLVD
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City | SAINT PAUL
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State | MN
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Zip | 55101-5302
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Country | US
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Telephone | 651-254-7729
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Fax |
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Provider Business Mailing Address
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Address Line | 1932 BAYARD AVE
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City | SAINT PAUL
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State | MN
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Zip | 55116-1215
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Country | US
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Telephone | 651-699-8906
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4267
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License Number State | MN
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