Provider Demographics
NPI:1710261052
Name:BROSSART, JENNIFER H (PT/LATC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:H
Last Name:BROSSART
Suffix:
Gender:F
Credentials:PT/LATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:H
Other - Last Name:LUNDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT/LATC
Mailing Address - Street 1:800 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368-2118
Mailing Address - Country:US
Mailing Address - Phone:701-776-5261
Mailing Address - Fax:701-776-5448
Practice Address - Street 1:800 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:RUGBY
Practice Address - State:ND
Practice Address - Zip Code:58368-2118
Practice Address - Country:US
Practice Address - Phone:701-776-5261
Practice Address - Fax:701-776-5448
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54539Medicaid