Provider Demographics
NPI:1679103840
Name:BLAISDELL, JESSICA (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 72ND ST N
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-2079
Mailing Address - Country:US
Mailing Address - Phone:651-497-6997
Mailing Address - Fax:
Practice Address - Street 1:75 VIKING DR W STE 101
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1778
Practice Address - Country:US
Practice Address - Phone:651-756-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist