Healthcare Provider Details

I. General information

NPI: 1124309372
Provider Name (Legal Business Name): JENNIFER K NELSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1997 SLOAN PL STE 17
MAPLEWOOD MN
55117-2051
US

IV. Provider business mailing address

2854 HIGHWAY 55 SUITE 130
EAGAN MN
55121-2156
US

V. Phone/Fax

Practice location:
  • Phone: 651-772-6251
  • Fax: 651-224-9661
Mailing address:
  • Phone: 651-842-3378
  • Fax: 651-224-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10980
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: