Provider Demographics
NPI:1013409879
Name:JESKA, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:JESKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14635 PENNOCK AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6588
Mailing Address - Country:US
Mailing Address - Phone:651-994-9644
Mailing Address - Fax:
Practice Address - Street 1:14635 PENNOCK AVE STE 300
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6588
Practice Address - Country:US
Practice Address - Phone:651-994-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105675225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1013409879Medicaid