Provider Demographics
NPI:1689723629
Name:DETERT, JENIFER KAREN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENIFER
Middle Name:KAREN
Last Name:DETERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENIFER
Other - Middle Name:KAREN
Other - Last Name:VETTLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9808 JENNY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-9692
Mailing Address - Country:US
Mailing Address - Phone:320-363-1150
Mailing Address - Fax:
Practice Address - Street 1:CENTRAL MINNESOTA EMERGENCY PHYSICIANS
Practice Address - Street 2:1406 6TH AVENUE NORTH
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-255-5656
Practice Address - Fax:320-656-7044
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9545OtherSTATE REGISTRATION NUMBER