Provider Demographics
NPI:1013456292
Name:DIFFERDING, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:DIFFERDING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3579 US HIGHWAY 75
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-9467
Mailing Address - Country:US
Mailing Address - Phone:701-403-4021
Mailing Address - Fax:
Practice Address - Street 1:3579 US HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-9467
Practice Address - Country:US
Practice Address - Phone:701-403-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer