Provider Demographics
NPI:1497225742
Name:LYNCH, JESSICA (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7355 COUNTY ROAD 140
Mailing Address - Street 2:
Mailing Address - City:COLOGNE
Mailing Address - State:MN
Mailing Address - Zip Code:55322-9161
Mailing Address - Country:US
Mailing Address - Phone:952-649-7071
Mailing Address - Fax:
Practice Address - Street 1:2015 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1446
Practice Address - Country:US
Practice Address - Phone:320-864-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11134208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11134OtherMINNESOTA BOARD OF PHYSICAL THERAPY