Provider Demographics
NPI:1336813229
Name:ANDERSON, JESICA MARIE
Entity Type:Individual
Prefix:
First Name:JESICA
Middle Name:MARIE
Last Name:ANDERSON
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 1:1435 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2667
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:495-244-3460
Practice Address - Street 1:1435 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2667
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:952-443-4604
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program