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General NPI Number Information
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NPI Number | 1992113203
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Entity Type | Individual
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Provider Name | TARA MARIE JAEGER PT, DPT, ATC
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Gender | Female
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Dates
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Enumeration Date | 07/30/2014
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Last Update Date | 11/17/2022
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Provider Practice Location Address
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Address Line | 3491 UNIVERSITY DR S
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City | FARGO
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State | ND
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Zip | 58104-6225
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Country | US
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Telephone | 701-412-1873
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Fax |
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Provider Business Mailing Address
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Address Line | 3426 23RD ST S
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City | MOORHEAD
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State | MN
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Zip | 56560-5314
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Country | US
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Telephone | 701-412-1873
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 471-12
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 1993
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License Number State | ND
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1993
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License Number State | ND
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