Provider Demographics
NPI:1639824519
Name:WOLF, JEREMY RYAN
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1639
Mailing Address - Country:US
Mailing Address - Phone:507-831-1731
Mailing Address - Fax:
Practice Address - Street 1:914 4TH AVE
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1639
Practice Address - Country:US
Practice Address - Phone:507-831-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist