Provider Demographics
NPI:1366728412
Name:JANUSZEWSKI, JACOB MARK (PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MARK
Last Name:JANUSZEWSKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-4113
Mailing Address - Country:US
Mailing Address - Phone:218-863-2000
Mailing Address - Fax:
Practice Address - Street 1:301 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572-4113
Practice Address - Country:US
Practice Address - Phone:218-863-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1570225100000X
MN8522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1366728412Medicaid
MN1366728412Medicaid