Provider Demographics
NPI:1669064895
Name:IMOTO, JARRYD PATRICK (DC)
Entity type:Individual
Prefix:DR
First Name:JARRYD
Middle Name:PATRICK
Last Name:IMOTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COMMERCE DR STE 260
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9243
Mailing Address - Country:US
Mailing Address - Phone:651-330-9453
Mailing Address - Fax:651-330-9453
Practice Address - Street 1:700 COMMERCE DR STE 260
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9243
Practice Address - Country:US
Practice Address - Phone:651-330-9453
Practice Address - Fax:651-330-9453
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61137000111NR0400X
MN7202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH61137000OtherCHIROPRACTIC LICENSE