Healthcare Provider Details

I. General information

NPI: 1083029920
Provider Name (Legal Business Name): JESSICA JANE KOLB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 WEBBER PKWY
MINNEAPOLIS MN
55412-1747
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-5750
  • Fax: 763-581-5751
Mailing address:
  • Phone: 763-520-5200
  • Fax: 763-581-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA142616
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64616
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: