Provider Demographics
NPI:1558472860
Name:PENA, JENNIFER M (ANP, GNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:PENA
Suffix:
Gender:F
Credentials:ANP, GNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:SUITE H2100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-3900
Practice Address - Fax:612-863-1681
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1542350363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q73088Medicare UPIN