Provider Demographics
NPI:1669553897
Name:BREKHUS, JENNIFER LEE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:BREKHUS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:121 ANTLER DR
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-8923
Mailing Address - Country:US
Mailing Address - Phone:701-351-3907
Mailing Address - Fax:
Practice Address - Street 1:210 HIGHWAY 2 W STE 7
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2913
Practice Address - Country:US
Practice Address - Phone:701-351-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51143Medicaid
ND27007OtherNORIDIAN
MN99G48PEOtherBCBS MN
ND27007OtherBCBS ND
ND27008OtherBCBS ND
ND27007OtherNORIDIAN