Healthcare Provider Details

I. General information

NPI: 1700083680
Provider Name (Legal Business Name): JENNIFER L DERRICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001
US

IV. Provider business mailing address

1025 MARSH ST
MANKATO MN
56001-4752
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-4031
  • Fax:
Mailing address:
  • Phone: 507-625-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50807
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number50807
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2086H0002X
TaxonomyHospice and Palliative Medicine (Surgery) Physician
License Number102956-875
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code2086H0002X
TaxonomyHospice and Palliative Medicine (Surgery) Physician
License Number50807
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: