Healthcare Provider Details

I. General information

NPI: 1376832345
Provider Name (Legal Business Name): JESSE MATTHEW COENEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W SUPERIOR ST STE. 220
DULUTH MN
55802-1701
US

IV. Provider business mailing address

324 W SUPERIOR ST STE. 220
DULUTH MN
55802-1701
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-3500
  • Fax: 218-249-3555
Mailing address:
  • Phone: 218-249-3500
  • Fax: 218-249-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60414
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number60414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: