Provider Demographics
NPI:1386891919
Name:BASTIAN, JENNIFER DANIELLE (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DANIELLE
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DANIELLE
Other - Last Name:MESSINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1131 E SUPERIOR ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2221
Mailing Address - Country:US
Mailing Address - Phone:218-625-6300
Mailing Address - Fax:218-724-6700
Practice Address - Street 1:1131 E SUPERIOR ST
Practice Address - Street 2:SUITE 202
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2221
Practice Address - Country:US
Practice Address - Phone:218-625-6300
Practice Address - Fax:218-724-6700
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist