Provider Demographics
NPI:1730424086
Name:HANSEN, JARED WADE
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:WADE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 AQUILA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3136
Mailing Address - Country:US
Mailing Address - Phone:641-512-4275
Mailing Address - Fax:
Practice Address - Street 1:2319 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2813
Practice Address - Country:US
Practice Address - Phone:651-251-3078
Practice Address - Fax:651-698-3910
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1456225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant