Provider Demographics
NPI:1215318670
Name:SEVERSON, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14884 KIRKWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8451
Practice Address - Country:US
Practice Address - Phone:218-824-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist