Healthcare Provider Details

I. General information

NPI: 1033212584
Provider Name (Legal Business Name): JENNIFER ANN GOUDY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 W 66TH ST SUITE 100
EDINA MN
55435-2528
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 900
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-0970
  • Fax: 952-922-1605
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: