Provider Demographics
NPI:1750303244
Name:JESSEN, MANDY SUMMER (NP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:SUMMER
Last Name:JESSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:SUMMER
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6161
Mailing Address - Fax:701-234-3861
Practice Address - Street 1:737 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-4811
Practice Address - Fax:701-234-6979
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR28421363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q23360Medicare UPIN