Provider Demographics
NPI:1124309372
Name:NELSON, JENNIFER K (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2156
Mailing Address - Country:US
Mailing Address - Phone:651-842-3378
Mailing Address - Fax:651-224-5273
Practice Address - Street 1:1997 SLOAN PL STE 17
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117-2051
Practice Address - Country:US
Practice Address - Phone:651-772-6251
Practice Address - Fax:651-224-9661
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN10980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1124309372Medicaid
MN1124309372Medicaid