Healthcare Provider Details

I. General information

NPI: 1205348802
Provider Name (Legal Business Name): JESSICA LOUISE HAAS LN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2017
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 26TH AVE S
MINNEAPOLIS MN
55406-3014
US

IV. Provider business mailing address

3840 26TH AVE S
MINNEAPOLIS MN
55406-3014
US

V. Phone/Fax

Practice location:
  • Phone: 612-964-2938
  • Fax:
Mailing address:
  • Phone: 612-964-2938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberN224
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: