Provider Demographics
NPI:1770599821
Name:JACKLITCH, JESSICA M (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:JACKLITCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3111 124TH AVE NW STE 123
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4573
Mailing Address - Country:US
Mailing Address - Phone:763-236-8955
Mailing Address - Fax:637-236-8966
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 405
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-236-0888
Practice Address - Fax:763-236-0885
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64-03344OtherMEDICA
MNHP43276OtherHEALTHPARTNERS
MN245J4NOOtherBCBS - MINNESOTA