Provider Demographics
NPI:1457923997
Name:BRAATEN, JACQUELINE (L/PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BRAATEN
Suffix:
Gender:F
Credentials:L/PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 VISTA OAKS DR SW
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2491
Mailing Address - Country:US
Mailing Address - Phone:218-820-7539
Mailing Address - Fax:
Practice Address - Street 1:804 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4441
Practice Address - Country:US
Practice Address - Phone:218-829-1407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA-3225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA-3OtherPHYSICAL THERAPIST ASSISTANT