Healthcare Provider Details

I. General information

NPI: 1033001862
Provider Name (Legal Business Name): JENNA KAY RETTERATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 WESTRAC DR S
FARGO ND
58103-2338
US

IV. Provider business mailing address

1202 WESTRAC DR S
FARGO ND
58103-2338
US

V. Phone/Fax

Practice location:
  • Phone: 701-850-7908
  • Fax:
Mailing address:
  • Phone: 701-460-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: