Provider Demographics
NPI:1861879868
Name:DIERCKS, JONATHON (MS, ATR, ATC)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:DIERCKS
Suffix:
Gender:M
Credentials:MS, ATR, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 AMERICAN BLVD W
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 AMERICAN BLVD W
Practice Address - Street 2:SUITE 2
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4420
Practice Address - Country:US
Practice Address - Phone:952-993-9706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer