Provider Demographics
NPI:1619064029
Name:JORUD, BRENT DANIEL (PT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DANIEL
Last Name:JORUD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:DANIEL
Other - Last Name:JORUD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:1655 BEAM AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1163
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN694467100Medicaid
WI40374000Medicaid
MNHP34973OtherHEALTHPARTNERS
MN193K3JOOtherBLUECROSS BLUESHIELD
MN650000714Medicare ID - Type UnspecifiedPART B