Provider Demographics
NPI:1396347878
Name:TOEDTER, JAKE PHILLIP (DPT)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:PHILLIP
Last Name:TOEDTER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 HART BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8539
Mailing Address - Country:US
Mailing Address - Phone:763-295-6878
Mailing Address - Fax:
Practice Address - Street 1:1107 HART BLVD STE 10
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8539
Practice Address - Country:US
Practice Address - Phone:763-295-6878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist