Provider Demographics
NPI:1528598760
Name:KANE, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:KANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CARLSON PKWY N STE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:763-367-7110
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 498A
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-8259
Practice Address - Country:US
Practice Address - Phone:314-251-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0252207N00000X
MA271107207R00000X
MO2022012789207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine