Provider Demographics
NPI:1437876919
Name:MISTRY, JENNIFER (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MISTRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4869 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1703
Mailing Address - Country:US
Mailing Address - Phone:715-651-9728
Mailing Address - Fax:
Practice Address - Street 1:4869 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1703
Practice Address - Country:US
Practice Address - Phone:715-651-9728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4019-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant