Provider Demographics
NPI:1730621095
Name:WENDT, JACOB ALAN (PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALAN
Last Name:WENDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 RADIO DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-3237
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:4040 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-3237
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103389225100000X
MN10843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist