Provider Demographics
NPI:1336394659
Name:MISKOVICH, JESSICA MARIE (DPT)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:MISKOVICH
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:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:PENGILLY
Mailing Address - State:MN
Mailing Address - Zip Code:55775-0307
Mailing Address - Country:US
Mailing Address - Phone:218-259-9862
Mailing Address - Fax:
Practice Address - Street 1:16015 BADAVINAC ROAD
Practice Address - Street 2:
Practice Address - City:PENGILLY
Practice Address - State:MN
Practice Address - Zip Code:55775-0307
Practice Address - Country:US
Practice Address - Phone:218-259-9862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650002432Medicare PIN