Basic Information
| Provider Information | |||||||||
| NPI: | 1003230137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEHN | ||||||||
| FirstName: | JANELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 636 BROADWAY ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127461530 | ||||||||
| FaxNumber: | 6127461531 | ||||||||
| Practice Location | |||||||||
| Address1: | 4342 4TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554092155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128229030 | ||||||||
| FaxNumber: | 6128212818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 125J00000X | DT38 | MN | Y | Dental Providers | Dental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1992822290 | 05 | MN | MEDICAID |