Provider Demographics
NPI:1487007332
Name:CARLSON, JEANETTE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:LYNN
Other - Last Name:WILIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:913 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57793-3045
Mailing Address - Country:US
Mailing Address - Phone:605-645-1836
Mailing Address - Fax:
Practice Address - Street 1:1420 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-717-8595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily