Provider Demographics
NPI:1679866099
Name:WHELAN, JESSICA K (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:K
Last Name:WHELAN
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 1:1106 SCARBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4801
Mailing Address - Country:US
Mailing Address - Phone:239-285-9646
Mailing Address - Fax:
Practice Address - Street 1:2945 HAZELWOOD ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1241
Practice Address - Country:US
Practice Address - Phone:651-232-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47356207Q00000X
MN63013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine