Healthcare Provider Details

I. General information

NPI: 1073622759
Provider Name (Legal Business Name): JENNIFER RENE NIMERICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKETPOINTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

3082 WILLOW DR
MEDINA MN
55340-9799
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-9880
  • Fax: 952-857-1554
Mailing address:
  • Phone: 512-799-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301078020
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM5410
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1614
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number70378
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036168703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: