Healthcare Provider Details

I. General information

NPI: 1710929880
Provider Name (Legal Business Name): JENNIFER K PEDERSON RDN, LD, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HUNDERTMARK RD STE 115N
CHASKA MN
55318-1584
US

IV. Provider business mailing address

111 HUNDERTMARK RD STE 115N
CHASKA MN
55318-1584
US

V. Phone/Fax

Practice location:
  • Phone: 952-361-2450
  • Fax: 952-361-2461
Mailing address:
  • Phone: 952-361-2450
  • Fax: 952-361-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1269
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: