Healthcare Provider Details

I. General information

NPI: 1164526299
Provider Name (Legal Business Name): JENNIFER N MARTINSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE
ST CLOUD MN
56303
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE
ST CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax: 320-654-3657
Mailing address:
  • Phone: 320-654-3630
  • Fax: 320-654-3657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number102429
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: