Healthcare Provider Details

I. General information

NPI: 1801678990
Provider Name (Legal Business Name): JENNA ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA ANDERSON LPN

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 W DAKOTA PKWY
WILLISTON ND
58801-3807
US

IV. Provider business mailing address

3600 LONG BRANCH AVE
WILLISTON ND
58801-2985
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-7711
  • Fax:
Mailing address:
  • Phone: 701-269-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR53286
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: