Provider Demographics
NPI:1114288933
Name:BROTTLUND, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROTTLUND
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:
Practice Address - Street 1:3955 56TH ST S STE D
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4845
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-3515
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND13699207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine