Healthcare Provider Details

I. General information

NPI: 1518885300
Provider Name (Legal Business Name): JESSICA NIESEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA VU

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 LOIS LN
LINO LAKES MN
55014-5498
US

IV. Provider business mailing address

674 LOIS LN
LINO LAKES MN
55014-5498
US

V. Phone/Fax

Practice location:
  • Phone: 952-258-3437
  • Fax:
Mailing address:
  • Phone: 952-258-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number126953
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: