Basic Information
| Provider Information | |||||||||
| NPI: | 1235626532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALLON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8450 SEASONS PKWY | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517025300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2018 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 71202 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.