Provider Demographics
NPI:1710929880
Name:PEDERSON, JENNIFER K (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:K
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W 98TH ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-4773
Mailing Address - Country:US
Mailing Address - Phone:952-885-6170
Mailing Address - Fax:952-885-6180
Practice Address - Street 1:600 W 98TH ST
Practice Address - Street 2:SUITE 20
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:952-885-6170
Practice Address - Fax:952-885-6180
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710000522Medicare Oscar/Certification
MN710000384Medicare Oscar/Certification