Healthcare Provider Details

I. General information

NPI: 1316184229
Provider Name (Legal Business Name): JESSICA RAE HOLST RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA RAE ABERG RD

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 HOUSTON ST NW STE 2
PRESTON MN
55965-1094
US

IV. Provider business mailing address

902 HOUSTON ST NW STE 2
PRESTON MN
55965-1094
US

V. Phone/Fax

Practice location:
  • Phone: 507-765-3898
  • Fax: 507-765-3898
Mailing address:
  • Phone: 507-765-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3305
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2161
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: