Provider Demographics
NPI:1659374387
Name:RABE, JESSICA JANE (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANE
Last Name:RABE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JANE
Other - Last Name:BUBOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10325 166TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8785
Mailing Address - Country:US
Mailing Address - Phone:952-435-2476
Mailing Address - Fax:
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:STE 160
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8575
Practice Address - Country:US
Practice Address - Phone:952-431-5353
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist