Provider Demographics
NPI:1144587650
Name:MADSEN, JERRY LYNN (RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LYNN
Last Name:MADSEN
Suffix:
Gender:M
Credentials:RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-7521
Mailing Address - Country:US
Mailing Address - Phone:507-398-4313
Mailing Address - Fax:
Practice Address - Street 1:4720 BURNING TREE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2634
Practice Address - Country:US
Practice Address - Phone:218-623-1800
Practice Address - Fax:218-623-1811
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR83926-8163W00000X, 163WC1500X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health