Provider Demographics
NPI:1871680454
Name:PETERSON, JENNIFER KAY (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KAY
Other - Last Name:GIROUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11671 FOUNTAINS DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4711
Mailing Address - Country:US
Mailing Address - Phone:763-420-2767
Mailing Address - Fax:
Practice Address - Street 1:11671 FOUNTAINS DR
Practice Address - Street 2:SUITE 220
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4711
Practice Address - Country:US
Practice Address - Phone:763-420-2767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist