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General NPI Number Information
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NPI Number | 1114288933
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Entity Type | Individual
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Provider Name | JENNIFER BROTTLUND MD
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Gender | Female
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Dates
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Enumeration Date | 06/07/2012
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Last Update Date | 04/29/2022
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Provider Practice Location Address
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Address Line | 3955 56TH ST S STE D
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City | FARGO
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State | ND
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Zip | 58104-4845
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Country | US
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Telephone | 701-234-2000
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Fax | 701-234-3515
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Provider Business Mailing Address
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Address Line | PO BOX 6001
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City | FARGO
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State | ND
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Zip | 58108-6001
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Country | US
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Telephone | 701-364-3300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 13699
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License Number State | ND
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