Provider Demographics
NPI:1457327363
Name:HALES, JEREMIAH (MS,LPT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:HALES
Suffix:
Gender:M
Credentials:MS,LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 W 98TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-2040
Mailing Address - Country:US
Mailing Address - Phone:612-226-5729
Mailing Address - Fax:
Practice Address - Street 1:5107 W 98TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-2040
Practice Address - Country:US
Practice Address - Phone:612-226-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN423915600Medicaid
77G34HAOtherBLUE CROSS BLUE SHIELD
650001442Medicare PIN