Provider Demographics
NPI:1770641227
Name:GROSSMAN, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 LIBERTY CIR
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4545
Mailing Address - Country:US
Mailing Address - Phone:612-743-5210
Mailing Address - Fax:
Practice Address - Street 1:2014 JEFFERSON RD
Practice Address - Street 2:NORTHFIELD URGENT CARE
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3251
Practice Address - Country:US
Practice Address - Phone:507-664-9999
Practice Address - Fax:507-664-3954
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10216363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN896493000Medicaid
MNQ51342Medicare UPIN
MN970002858Medicare ID - Type Unspecified