Provider Demographics
NPI:1265105498
Name:CARLSON, JOLENE MARGARET (LN)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:MARGARET
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:45 SNELLING AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6842
Mailing Address - Country:US
Mailing Address - Phone:651-699-3438
Mailing Address - Fax:651-695-0191
Practice Address - Street 1:1250 WAYZATA BLVD E
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1951
Practice Address - Country:US
Practice Address - Phone:952-345-0766
Practice Address - Fax:651-695-0191
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNN240133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist