=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417605734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LIN DRESSEN LPN, IBCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2022
-----------------------------------------------------
Last Update Date | 12/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 348 W MAIN ST STE 202
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-401-2688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 POPLAR AVE N
-----------------------------------------------------
City | CANBY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56220-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-333-6734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 817183
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------