Provider Demographics
NPI:1619492006
Name:HEIMDAL, JONATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HEIMDAL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:JON
Other - Middle Name:D
Other - Last Name:HEIMDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:9645 GROVE CIR N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2684
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:
Practice Address - Street 1:7700 FRANCE AVE S STE 240
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5878
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist