Basic Information
| Provider Information | |||||||||
| NPI: | 1679866099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHELAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 SCARBOROUGH LN | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392859646 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2945 HAZELWOOD ST | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 01/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47356 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 63013 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.