MEDICARE: JACOB ALLEN WENDLAND D.P.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	8833	MN

General Provider Information

NPI Number	:	1285975078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ALLEN WENDLAND D.P.T

Provider Business Mailing Address
First Line	:	410 30TH AVE E STE 102
Second Line	:
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-4770
Country	:	US
Telephone Number	:	320-763-5505
Fax Number	:	320-763-4447

Provider Business Practice Location Address
First Line	:	1304 W LINCOLN AVE STE C
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-4818
Country	:	US
Telephone Number	:	218-998-0701
Fax Number	:	218-998-2425

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2013
Last Update Date	:	03/05/2013

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