MEDICARE: JENNIFER JOY WILLEMS NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11695	MN

General Provider Information

NPI Number	:	1073341228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER JOY WILLEMS NP-C

Provider Business Mailing Address
First Line	:	1342 COLORADO AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1220
Country	:	US
Telephone Number	:	952-546-5322
Fax Number	:

Provider Business Practice Location Address
First Line	:	1342 COLORADO AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1220
Country	:	US
Telephone Number	:	952-546-5322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2024
Last Update Date	:	07/22/2024

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