Provider Demographics
NPI:1558529685
Name:MARLEN, JEANNETTE RENAE
Entity Type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:RENAE
Last Name:MARLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JEANNETTE
Other - Middle Name:RENAE
Other - Last Name:AXTUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-0471
Mailing Address - Country:US
Mailing Address - Phone:218-334-2674
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0578626164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse