Provider Demographics
NPI:1619453115
Name:MUDGETT, JESSICA MAE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:MUDGETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12668 43RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2405
Mailing Address - Country:US
Mailing Address - Phone:218-839-1484
Mailing Address - Fax:
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF06181406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily