Provider Demographics
NPI:1558448373
Name:JOHNSRUD, JENNIFIER R (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFIER
Middle Name:R
Last Name:JOHNSRUD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFIER
Other - Middle Name:R
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3026 34TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-6937
Mailing Address - Country:US
Mailing Address - Phone:701-388-3956
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:SPORTS MEDICINE
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND310-062255A2300X
MN18992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer