Healthcare Provider Details

I. General information

NPI: 1275856239
Provider Name (Legal Business Name): JANA LEE MARTIN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANA LEE JANSON RD

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 WINNETKA AVE N
MINNEAPOLIS MN
55428-1619
US

IV. Provider business mailing address

7101 WINNETKA AVE N
BROOKLYN PARK MN
55428-1619
US

V. Phone/Fax

Practice location:
  • Phone: 320-237-5952
  • Fax:
Mailing address:
  • Phone: 320-237-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number980124
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number980124
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: