Healthcare Provider Details

I. General information

NPI: 1770879082
Provider Name (Legal Business Name): JESSICA SEWALSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SPRINGBROOK DR NW T-0820
COON RAPIDS MN
55433-6033
US

IV. Provider business mailing address

8600 SPRINGBROOK DR NW T-0820
COON RAPIDS MN
55433-6033
US

V. Phone/Fax

Practice location:
  • Phone: 763-785-0720
  • Fax: 763-785-0720
Mailing address:
  • Phone: 763-785-0720
  • Fax: 763-785-0720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118938
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: