Provider Demographics
NPI:1194359380
Name:HUMBERT, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:HUMBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2346
Mailing Address - Country:US
Mailing Address - Phone:651-315-5096
Mailing Address - Fax:
Practice Address - Street 1:1111 HOLCOMBE ST S
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5736
Practice Address - Country:US
Practice Address - Phone:651-315-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist