Provider Demographics
NPI:1982243903
Name:ERICKSON, JENNA ELIZABETH (CNM IBCLC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:CNM IBCLC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:ELIZABETH
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:425 241ST ST
Mailing Address - Street 2:
Mailing Address - City:BALATON
Mailing Address - State:MN
Mailing Address - Zip Code:56115-1107
Mailing Address - Country:US
Mailing Address - Phone:507-430-0636
Mailing Address - Fax:
Practice Address - Street 1:425 241ST ST
Practice Address - Street 2:
Practice Address - City:BALATON
Practice Address - State:MN
Practice Address - Zip Code:56115-1107
Practice Address - Country:US
Practice Address - Phone:507-430-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-193011-1163WL0100X
MN542367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant