Healthcare Provider Details

I. General information

NPI: 1538072483
Provider Name (Legal Business Name): JENNIFER LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 KELLER LAKE DR
BURNSVILLE MN
55306-6376
US

IV. Provider business mailing address

1713 KELLER LAKE DR
BURNSVILLE MN
55306-6376
US

V. Phone/Fax

Practice location:
  • Phone: 952-923-0698
  • Fax:
Mailing address:
  • Phone: 952-923-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: