Provider Demographics
NPI:1144650482
Name:GREVENGOED, JACLYN (PT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GREVENGOED
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 1:7505 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4501
Mailing Address - Country:US
Mailing Address - Phone:763-450-6902
Mailing Address - Fax:
Practice Address - Street 1:13616 CALIFORNIA ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5336
Practice Address - Country:US
Practice Address - Phone:402-496-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-23
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3922225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47081304012Medicaid