Provider Demographics
NPI:1538773601
Name:JAQUETTE, BRYAN JAMES (ATC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JAMES
Last Name:JAQUETTE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ALINA HEALTH
Mailing Address - Street 2:8100 WEST 78TH STREET, SUITE 225
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439
Mailing Address - Country:US
Mailing Address - Phone:952-946-9777
Mailing Address - Fax:
Practice Address - Street 1:ALINA HEALTH
Practice Address - Street 2:8100 WEST 78TH STREET, SUITE 225
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer