Provider Demographics
NPI:1891070694
Name:WAITE, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:WAITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2001 KILLEBREW DR
Mailing Address - Street 2:STE 308
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1886
Mailing Address - Country:US
Mailing Address - Phone:651-999-7022
Mailing Address - Fax:651-999-6970
Practice Address - Street 1:9825 HOSPITAL DR STE 205
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4480
Practice Address - Country:US
Practice Address - Phone:763-587-7000
Practice Address - Fax:763-587-7015
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X363A00000X
IL085.004163363AM0700X
MN13027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical