Healthcare Provider Details

I. General information

NPI: 1861787806
Provider Name (Legal Business Name): JENNIFER RENEE DAVIS RD,CD, LD, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9825 HOSPITAL DR
MAPLE GROVE MN
55369-4479
US

IV. Provider business mailing address

9825 HOSPITAL DR
MAPLE GROVE MN
55369-4479
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-8900
  • Fax:
Mailing address:
  • Phone: 763-581-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1897
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5996
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: