Provider Demographics
NPI:1407471642
Name:AYUSO, JAIME JR (DC, EMT)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:AYUSO
Suffix:JR
Gender:M
Credentials:DC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 FERNDALE ST S
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5946
Mailing Address - Country:US
Mailing Address - Phone:407-810-6094
Mailing Address - Fax:
Practice Address - Street 1:2501 W 84TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1602
Practice Address - Country:US
Practice Address - Phone:952-214-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407471642Medicaid