Provider Demographics
NPI:1255019634
Name:JERDIN, MICHELLE LEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:JERDIN
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 1:10740 COUNTY ROAD 37 NE APT 109
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-9663
Mailing Address - Country:US
Mailing Address - Phone:763-300-6995
Mailing Address - Fax:
Practice Address - Street 1:10740 COUNTY ROAD 37 NE APT 109
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-9663
Practice Address - Country:US
Practice Address - Phone:763-300-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN384639172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver