=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255717674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA M ATHERTON RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2015
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 SMITH AVE N
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-494-9761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18657 CLEAR VIEW CT
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-6087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-458-5130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 12580
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------