Provider Demographics
NPI:1851991566
Name:JEWETT, SUSAN M (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:JEWETT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8795
Practice Address - Country:US
Practice Address - Phone:218-246-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15260225100000X
MN11984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist