Provider Demographics
NPI:1396062923
Name:JAQUA, JONATHON DAVID (DO)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:DAVID
Last Name:JAQUA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 W. 65TH STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-920-7001
Mailing Address - Fax:952-345-0472
Practice Address - Street 1:3625 W. 65TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-920-7001
Practice Address - Fax:612-626-0665
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN57244207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program