Provider Demographics
NPI:1700300720
Name:MIKKELSON, JENNIFER L (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N STE 400
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2568
Practice Address - Country:US
Practice Address - Phone:651-290-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5282363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care