Provider Demographics
NPI:1578820775
Name:SHIN, JESSICA S (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:SHIN
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 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-6468
Mailing Address - Fax:
Practice Address - Street 1:4440 S. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147473207X00000X
UT10248520-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery