Provider Demographics
NPI:1053995670
Name:BELTZ, JEREMY JOHN (RN)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JOHN
Last Name:BELTZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10307 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-8026
Mailing Address - Country:US
Mailing Address - Phone:763-786-3439
Mailing Address - Fax:
Practice Address - Street 1:10307 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-8026
Practice Address - Country:US
Practice Address - Phone:763-786-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2475939163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA696845700Medicaid