Provider Demographics
NPI:1568214732
Name:KRUSE, JENNICA ANASTASIA
Entity Type:Individual
Prefix:
First Name:JENNICA
Middle Name:ANASTASIA
Last Name:KRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 22ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3743
Mailing Address - Country:US
Mailing Address - Phone:612-219-5098
Mailing Address - Fax:
Practice Address - Street 1:2637 27TH AVE S STE 248
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1565
Practice Address - Country:US
Practice Address - Phone:612-219-5098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist