Basic Information
| Provider Information | |||||||||
| NPI: | 1740247824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANGENES | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, RD, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 HARVARD ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122733000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 E NICOLLET BLVD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553375714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528922000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2335 | MN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 363A00000X | 1166732 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.