Provider Demographics
NPI:1689151185
Name:ELLERBUSCH, JAY VINCENT (DPT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:VINCENT
Last Name:ELLERBUSCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W 140TH ST
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4480
Mailing Address - Country:US
Mailing Address - Phone:952-808-3000
Mailing Address - Fax:
Practice Address - Street 1:1000 W 140TH ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4480
Practice Address - Country:US
Practice Address - Phone:952-808-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist