Provider Demographics
NPI:1407185523
Name:BANNICK, JEAN MICHELLE (MOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MICHELLE
Last Name:BANNICK
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 W 28TH ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3011
Mailing Address - Country:US
Mailing Address - Phone:651-698-0830
Mailing Address - Fax:
Practice Address - Street 1:7900 W 28TH ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3011
Practice Address - Country:US
Practice Address - Phone:651-698-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-19
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103792225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist