Provider Demographics
NPI:1003987132
Name:CARLSON, JEFFREY JAMES (M ED, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:M ED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3777 114TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2607
Mailing Address - Country:US
Mailing Address - Phone:763-323-1732
Mailing Address - Fax:
Practice Address - Street 1:2104 NORTHDALE BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3005
Practice Address - Country:US
Practice Address - Phone:763-755-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer