Provider Demographics
NPI:1396256392
Name:IDAHOR, JESSICA (DNP, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:IDAHOR
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 GROVE CIR N STE 100
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2682
Mailing Address - Country:US
Mailing Address - Phone:763-302-4114
Mailing Address - Fax:
Practice Address - Street 1:9645 GROVE CIR N STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-302-4114
Practice Address - Fax:763-302-4081
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5492363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner