Basic Information
| Provider Information | |||||||||
| NPI: | 1497987812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEFFIELD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1100 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015674561 | ||||||||
| FaxNumber: | 7015676301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 ST FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565201025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186430747 | ||||||||
| FaxNumber: | 2186430748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12484 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 65569 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000017243 | 05 | ND | MEDICAID |