Provider Demographics
NPI:1255828463
Name:VIK, JENNIFER REBECCA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:VIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 GRAND AVE TRLR 31
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55808-1308
Mailing Address - Country:US
Mailing Address - Phone:218-269-7109
Mailing Address - Fax:
Practice Address - Street 1:9428 GRAND AVE TRLR 31
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55808-1308
Practice Address - Country:US
Practice Address - Phone:218-269-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL60073-0164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse