Healthcare Provider Details

I. General information

NPI: 1740229095
Provider Name (Legal Business Name): JESSICA QUINONEZ-WEISLOW RD,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 BLUE GENTIAN RD SUITE 150
EAGAN MN
55121-1669
US

IV. Provider business mailing address

880 BLUE GENTIAN RD SUITE 150
EAGAN MN
55121-1669
US

V. Phone/Fax

Practice location:
  • Phone: 651-379-1600
  • Fax: 651-379-1650
Mailing address:
  • Phone: 651-379-1600
  • Fax: 651-379-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number2171
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: