Provider Demographics
NPI:1558330852
Name:CARLSON, JESSICA LORRAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LORRAINE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 E 28TH ST # MR 11326
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3723
Mailing Address - Country:US
Mailing Address - Phone:612-863-7560
Mailing Address - Fax:612-863-3809
Practice Address - Street 1:920 EAST 28TH STREET SUITE # 190
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-863-7560
Practice Address - Fax:612-863-3809
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I27354Medicare UPIN