Provider Demographics
NPI:1093072340
Name:METHERD, JENNIFER SACKRISON (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SACKRISON
Last Name:METHERD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 NICOLLET MALL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2500
Mailing Address - Country:US
Mailing Address - Phone:612-333-2503
Mailing Address - Fax:
Practice Address - Street 1:801 NICOLLET MALL
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2500
Practice Address - Country:US
Practice Address - Phone:612-333-2503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN60829207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN60829OtherSTATE LICENSE