Basic Information
Provider Information | |||||||||
NPI: | 1447694013 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONLEY | ||||||||
FirstName: | JACQUELYN | ||||||||
MiddleName: | LORRAINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENSEN | ||||||||
OtherFirstName: | JACQUELYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | GOLDEN VALLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554224841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528474029 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 CHASKA CREEK WAY STE 200 | ||||||||
Address2: |   | ||||||||
City: | CHASKA | ||||||||
State: | MN | ||||||||
PostalCode: | 553182749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528561046 | ||||||||
FaxNumber: | 9528561049 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2013 | ||||||||
LastUpdateDate: | 04/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 58068 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.