Provider Demographics
NPI:1346210432
Name:ELLINGSON, JACOB RYAN (MSPT, SCS, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:MSPT, SCS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HIGHWAY 65 S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1899
Mailing Address - Country:US
Mailing Address - Phone:320-225-3356
Mailing Address - Fax:320-225-3370
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-225-3356
Practice Address - Fax:320-225-3370
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN67492251S0007X
IA003672255A2300X
IA03255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
I3153Medicare ID - Type Unspecified
IA0243477Medicaid
IA28727OtherBLUE CROSS BLUE SHIELD