Basic Information
Provider Information | |||||||||
NPI: | 1124309372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2854 HIGHWAY 55 | ||||||||
Address2: | SUITE 130 | ||||||||
City: | EAGAN | ||||||||
State: | MN | ||||||||
PostalCode: | 551212156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6518423378 | ||||||||
FaxNumber: | 6512245273 | ||||||||
Practice Location | |||||||||
Address1: | 1997 SLOAN PL STE 17 | ||||||||
Address2: |   | ||||||||
City: | MAPLEWOOD | ||||||||
State: | MN | ||||||||
PostalCode: | 551172051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517726251 | ||||||||
FaxNumber: | 6512249661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2011 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10980 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1124309372 | 05 | MN |   | MEDICAID |