Provider Demographics
NPI:1982670956
Name:ENSTROM, JENNY E (PA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:E
Last Name:ENSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:MLLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1445
Practice Address - Country:US
Practice Address - Phone:763-587-4800
Practice Address - Fax:763-587-4845
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN286929200Medicaid
Q47594Medicare UPIN
MN286929200Medicaid