Provider Demographics
NPI:1740718014
Name:PIERSAK, JIETHYL
Entity type:Individual
Prefix:
First Name:JIETHYL
Middle Name:
Last Name:PIERSAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11926 UNDERCLIFF ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-1628
Mailing Address - Country:US
Mailing Address - Phone:952-913-9302
Mailing Address - Fax:
Practice Address - Street 1:2512 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1404
Practice Address - Country:US
Practice Address - Phone:612-273-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104824225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty