Provider Demographics
NPI:1730262494
Name:THEISEN, JO G (DC)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:G
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8465 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2266
Mailing Address - Country:US
Mailing Address - Phone:763-424-7750
Mailing Address - Fax:763-424-3444
Practice Address - Street 1:8465 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2266
Practice Address - Country:US
Practice Address - Phone:763-424-7750
Practice Address - Fax:763-424-3444
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2599111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN416728700Medicaid
1952484602OtherNPI FACILITY
MN416728700Medicaid
20 5692367OtherFACILITY TIN
MN416728700Medicaid
MNC04402Medicare ID - Type UnspecifiedFACILITY LEVEL MC ID