Healthcare Provider Details

I. General information

NPI: 1952915282
Provider Name (Legal Business Name): BRETT ANTHONY JAHNKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 NORTHWAY DR
SAINT CLOUD MN
56303-4555
US

IV. Provider business mailing address

2313 BRONCO LN
BUFFALO MN
55313-2929
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-1775
  • Fax:
Mailing address:
  • Phone: 320-522-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7508
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: