=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982372595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON JACOB THOMAS PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2021
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 SAINT FRANCIS AVE STE 200
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-3385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-892-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8418 GROVE PL
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-8518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-799-6544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 12429
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------