=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649162413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDOURA EFFECT, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2025
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1099 HELMO AVE N STE 230
-----------------------------------------------------
City | OAKDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55128-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-243-0625
-----------------------------------------------------
Fax | 855-462-3105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 N CEDAR AVE STE 1
-----------------------------------------------------
City | OWATONNA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55060-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-243-0625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JILLIAN SIMON
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 651-491-4946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------