Provider Demographics
NPI:1255860268
Name:NELSON, JESSIE LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LAUREN
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:LAUREN
Other - Last Name:MAROLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11225 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4261
Mailing Address - Country:US
Mailing Address - Phone:763-302-2600
Mailing Address - Fax:763-302-2601
Practice Address - Street 1:11225 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4261
Practice Address - Country:US
Practice Address - Phone:763-302-2600
Practice Address - Fax:763-302-2601
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant