Provider Demographics
NPI:1447641899
Name:REDDY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 BROADWAY N APT 204
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2671
Mailing Address - Country:US
Mailing Address - Phone:701-371-2756
Mailing Address - Fax:
Practice Address - Street 1:1021 BANDANA BLVD E STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5109
Practice Address - Country:US
Practice Address - Phone:651-241-9700
Practice Address - Fax:651-241-9678
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27882255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer