Provider Demographics
NPI:1033195813
Name:RYSSO, JENNIFER H
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:RYSSO
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 1:4695 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9715
Mailing Address - Country:US
Mailing Address - Phone:952-442-7890
Mailing Address - Fax:952-442-7894
Practice Address - Street 1:4695 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-9715
Practice Address - Country:US
Practice Address - Phone:952-442-7890
Practice Address - Fax:952-442-7894
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN318902300Medicaid
MNG44369Medicare UPIN