Provider Demographics
NPI:1700113982
Name:BACH, JENNIFER ELLEN (PT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ELLEN
Last Name:BACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 W 36 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4854
Mailing Address - Country:US
Mailing Address - Phone:952-927-9717
Mailing Address - Fax:
Practice Address - Street 1:4415 W 36 1/2 ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4854
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2011-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1121507225100000X
MN8683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist