Provider Demographics
NPI:1689759383
Name:PEDERSEN, JENNIFER ELYSE (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELYSE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3618
Mailing Address - Country:US
Mailing Address - Phone:218-844-5050
Mailing Address - Fax:218-844-5049
Practice Address - Street 1:1131 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3618
Practice Address - Country:US
Practice Address - Phone:218-844-5050
Practice Address - Fax:218-844-5049
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN575171100000X
MN4079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020960100Medicaid
242T6NOOtherCLINIC #
350002650OtherMEDICARE PROVIDER #
134208196OtherEMPLOYER # FED #
4079OtherLICENSE #
0908OtherHSM
242T7PEOtherBCBS PROVIDER #
89749OtherHEALTH PARTNERS
647163OtherCHIROCARE #
P00229402OtherRAILROAD
020960100OtherMHCP HEALTH CARE
575OtherACCUPUNCTURE #