=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861342578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN L GRANFORS
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2026
-----------------------------------------------------
Last Update Date | 02/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4572 COUNTY ROAD 61
-----------------------------------------------------
City | MOOSE LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55767-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-485-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5819 COUNTY ROAD 12
-----------------------------------------------------
City | KETTLE RIVER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55757-8640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-730-7426
-----------------------------------------------------
Fax | 218-730-7426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0102X
-----------------------------------------------------
Taxonomy Name | Maternal Newborn Registered Nurse
-----------------------------------------------------
License Number | 2213840
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------