Provider Demographics
NPI:1033663414
Name:RETTERATH, JESSICA (CRNA, APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RETTERATH
Suffix:
Gender:F
Credentials:CRNA, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 APPLE GLEN RD
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9429
Mailing Address - Country:US
Mailing Address - Phone:320-237-8616
Mailing Address - Fax:
Practice Address - Street 1:35 APPLE GLEN RD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-9429
Practice Address - Country:US
Practice Address - Phone:320-237-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1953033163W00000X
MNR195303-3163WC0200X
MNCRNA1958367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine