Healthcare Provider Details

I. General information

NPI: 1881730752
Provider Name (Legal Business Name): JENNIFER DICKENSON MCGILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax: 406-247-3389
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number87236
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1282
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15142
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: