MEDICARE: MRS. JESSICA JEWEL HAWLEY ATC

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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1538224100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA JEWEL HAWLEY ATC

Provider Business Mailing Address
First Line	:	4101 W 98TH ST APT 325
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55437-2131
Country	:	US
Telephone Number	:	952-220-1879
Fax Number	:

Provider Business Practice Location Address
First Line	:	6025 109TH AVE N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-3475
Country	:	US
Telephone Number	:	952-220-1879
Fax Number	:

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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