Provider Demographics
NPI:1114285012
Name:HEDTKE, JENNIFER LEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:HEDTKE
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 1:18580 JOPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4218
Mailing Address - Country:US
Mailing Address - Phone:952-892-9500
Mailing Address - Fax:
Practice Address - Street 1:18580 JOPLIN AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4218
Practice Address - Country:US
Practice Address - Phone:952-892-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine