Provider Demographics
NPI:1821582990
Name:RISSE, JENNIFER (CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RISSE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MAJOR ALLEN
Mailing Address - Street 2:PO BOX 70D
Mailing Address - City:MARTIN
Mailing Address - State:SD
Mailing Address - Zip Code:57551-6305
Mailing Address - Country:US
Mailing Address - Phone:605-685-1660
Mailing Address - Fax:605-685-1166
Practice Address - Street 1:102 MAJOR ALLEN ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:SD
Practice Address - Zip Code:57551-6005
Practice Address - Country:US
Practice Address - Phone:605-685-1660
Practice Address - Fax:605-685-1166
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001390363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP001390OtherSD BON