=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457904732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAZMINE MARIE NESVIK DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2019
-----------------------------------------------------
Last Update Date | 10/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 18TH AVE E
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-762-6107
-----------------------------------------------------
Fax | 320-759-4327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 30TH AVE W
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-763-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 2019022955
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------