Provider Demographics
NPI:1124129614
Name:JURGENS-DINIUS, NICHOLL (PT)
Entity type:Individual
Prefix:
First Name:NICHOLL
Middle Name:
Last Name:JURGENS-DINIUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 W VILLARD ST STE A
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4651
Mailing Address - Country:US
Mailing Address - Phone:701-225-7575
Mailing Address - Fax:701-225-9697
Practice Address - Street 1:1531 W VILLARD ST STE A
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4651
Practice Address - Country:US
Practice Address - Phone:701-225-7575
Practice Address - Fax:701-225-9697
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND23726OtherBLUE CROSS
ND54648Medicaid
ND23726OtherBLUE CROSS