Provider Demographics
NPI:1659069730
Name:JESOK, KELLY PAUL (LPN)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:PAUL
Last Name:JESOK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 265TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-5258
Mailing Address - Country:US
Mailing Address - Phone:612-513-5803
Mailing Address - Fax:
Practice Address - Street 1:6465 WAYZATA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-1750
Practice Address - Country:US
Practice Address - Phone:763-546-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN814568164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse