Healthcare Provider Details

I. General information

NPI: 1750173035
Provider Name (Legal Business Name): MITCHELL FORREST JAEGER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR ST 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

6930 U. S. HIGHWAY 71
WILLMAR MN
56201
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-4574
  • Fax:
Mailing address:
  • Phone: 715-351-0830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: