Provider Demographics
NPI:1215489448
Name:REQUEJO, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REQUEJO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14670 BRUNSWICK AVE S
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2856
Mailing Address - Country:US
Mailing Address - Phone:507-676-6208
Mailing Address - Fax:
Practice Address - Street 1:512 49TH AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3621
Practice Address - Country:US
Practice Address - Phone:612-607-5807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist