Provider Demographics
NPI:1295956910
Name:JAENICKE, SCOT H (ATC)
Entity type:Individual
Prefix:
First Name:SCOT
Middle Name:H
Last Name:JAENICKE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13607 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4133
Mailing Address - Country:US
Mailing Address - Phone:952-898-2146
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:763-533-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer