Provider Demographics
NPI:1194248468
Name:SIMMONS, JEANNINE MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:MARIE
Last Name:SIMMONS
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 1:1641 KENABEC ST
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9412
Mailing Address - Country:US
Mailing Address - Phone:763-291-9413
Mailing Address - Fax:
Practice Address - Street 1:1810 MINNESOTA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-2436
Practice Address - Country:US
Practice Address - Phone:320-252-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1953225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA1953OtherPHYSICAL THERAPIST ASSISTANT