Healthcare Provider Details

I. General information

NPI: 1669553897
Provider Name (Legal Business Name): JENNIFER LEE NELSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEE PEDERSON DPT

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HIGHWAY 2 W STE 7
DEVILS LAKE ND
58301-2913
US

IV. Provider business mailing address

121 ANTLER DR
DEVILS LAKE ND
58301-8923
US

V. Phone/Fax

Practice location:
  • Phone: 701-351-3907
  • Fax:
Mailing address:
  • Phone: 701-351-3907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1409
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: