Provider Demographics
NPI:1457471054
Name:DONNER, JEREMY RICHARD (ATC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:RICHARD
Last Name:DONNER
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 1:3601 PHILLIPS PKWY APT 208
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3875
Mailing Address - Country:US
Mailing Address - Phone:952-836-8967
Mailing Address - Fax:
Practice Address - Street 1:701 25TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1513
Practice Address - Country:US
Practice Address - Phone:612-672-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1920174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist