Provider Demographics
NPI:1962950667
Name:BUCKWALTER, JENNA (DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BUCKWALTER
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 1:430 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1426
Mailing Address - Country:US
Mailing Address - Phone:218-641-7725
Mailing Address - Fax:
Practice Address - Street 1:430 5TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1426
Practice Address - Country:US
Practice Address - Phone:218-641-7725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9959314000000X, 225100000X
ND1732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1469913Medicaid
ND1469913Medicaid