Healthcare Provider Details

I. General information

NPI: 1861651473
Provider Name (Legal Business Name): CAROLYN ANN JAHR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN ANN GUILLEMETTE

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST
DULUTH MN
55805-1951
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10459
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: