Healthcare Provider Details

I. General information

NPI: 1861428385
Provider Name (Legal Business Name): JENNIFER C DURST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 BANDANA BLVD W
SAINT PAUL MN
55108-5107
US

IV. Provider business mailing address

2009 TREMONT AVE
FORT WORTH TX
76107-3959
US

V. Phone/Fax

Practice location:
  • Phone: 651-641-7000
  • Fax: 651-641-7166
Mailing address:
  • Phone: 651-642-2700
  • Fax: 651-642-9441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9383
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: