Provider Demographics
NPI:1588388912
Name:ELLINGSON, JENNA M
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16600 810TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56036-4172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16600 810TH AVE
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:MN
Practice Address - Zip Code:56036-4172
Practice Address - Country:US
Practice Address - Phone:641-390-0462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach