Provider Demographics
NPI:1881031706
Name:TATE, JENNA LEIGH (DO)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:TATE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LEIGH
Other - Last Name:MARTENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14829 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-3637
Mailing Address - Country:US
Mailing Address - Phone:952-457-2663
Mailing Address - Fax:
Practice Address - Street 1:14050 NICOLLET AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5710
Practice Address - Country:US
Practice Address - Phone:952-435-2450
Practice Address - Fax:952-892-0217
Is Sole Proprietor?:No
Enumeration Date:2013-06-01
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR9745208000000X
MN60599208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics