Basic Information
| Provider Information | |||||||||
| NPI: | 1083296024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANCETTE | ||||||||
| FirstName: | JESICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1687 WOODLANE DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551253047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513270849 | ||||||||
| FaxNumber: | 6513834557 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 WOODLANE DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551253047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513270849 | ||||||||
| FaxNumber: | 6513834557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1649815614 | 01 | MN | GROUP NPI | OTHER |