Provider Demographics
NPI:1972659894
Name:PETERSEN MOREHEAD, JACQUELINE LEE (PHYSICAL THERAPY)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LEE
Last Name:PETERSEN MOREHEAD
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY
Other - Prefix:
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Mailing Address - Street 1:1932 BAYARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1215
Mailing Address - Country:US
Mailing Address - Phone:651-699-8906
Mailing Address - Fax:
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist