Doctor Name: | JACOB RYAN ELLINGSON |
NPI Number: | 1346210432 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MSPT, SCS, ATC, CSCS |
License Number: | 6749 |
Business Practice Address: | 301 Highway 65 S Mora, MN - 550511899 |
Business Phone Number: | 3202253356 |
Business Fax Number: | 3202253370 |
Mailing Address: | 301 Highway 65 S, MORA |
State: | MN |
Postal Code: | 550511899 |
Phone Number: | 3202253356 |
Fax Number: | 3202253370 |
NPI Enumeration Date: | 01/23/2006 |
NPI Last Update Date: | 07/09/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 2251S0007X |
License Number: | 6749 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
Taxonomy Classification: | Physical Therapist |
Taxonomy Specialization: | Sports |
Taxonomy Definition: |