Healthcare Provider Details

I. General information

NPI: 1396560801
Provider Name (Legal Business Name): JENNIFER DUBEAU BEDARD-PARKER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

IV. Provider business mailing address

752 GRAND AVE
SAINT PAUL MN
55105-3306
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax:
Mailing address:
  • Phone: 651-842-3003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11914
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: