Provider Demographics
NPI:1336503390
Name:DOUGLAS, JEFFREY (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN STE 120
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5338
Mailing Address - Country:US
Mailing Address - Phone:763-220-6064
Mailing Address - Fax:
Practice Address - Street 1:11995 SINGLETREE LN STE 120
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5338
Practice Address - Country:US
Practice Address - Phone:763-220-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 43872255A2300X
MN10977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty