Provider Demographics
NPI:1164678660
Name:MARSDEN, JENNY K (PA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:K
Last Name:MARSDEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 8TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3604
Mailing Address - Country:US
Mailing Address - Phone:701-234-3260
Mailing Address - Fax:
Practice Address - Street 1:1301 8TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3604
Practice Address - Country:US
Practice Address - Phone:701-234-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0398363AS0400X
MN10899363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71105Medicaid
ND970012209OtherRAILROAD MEDICARE
NDPAC0398OtherSTATE LICENSE
NDPAC0398OtherSTATE LICENSE
ND71105Medicaid