Provider Demographics
NPI:1932512076
Name:STANGLAND, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:STANGLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 3RD ST N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5447
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:
Practice Address - Street 1:12324 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1919
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1096973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered