Provider Demographics
NPI:1659001527
Name:HERCHENHAHN, JILL (CMT, NCBTMB,)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:HERCHENHAHN
Suffix:
Gender:F
Credentials:CMT, NCBTMB,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 2ND AVE S STE 55
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 2ND AVE S STE 55
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1246
Practice Address - Country:US
Practice Address - Phone:320-267-1803
Practice Address - Fax:320-281-3007
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN778052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN778052OtherNATIONAL REGISTRY