Provider Demographics
NPI:1003548256
Name:LECLAIRE, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LECLAIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6670 131ST ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4104
Mailing Address - Country:US
Mailing Address - Phone:952-693-6285
Mailing Address - Fax:
Practice Address - Street 1:303 E NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4522
Practice Address - Country:US
Practice Address - Phone:952-460-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9266363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner