Provider Demographics
NPI:1801678990
Name:ANDERSON, JENNA (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3600 LONG BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2985
Mailing Address - Country:US
Mailing Address - Phone:701-269-2353
Mailing Address - Fax:
Practice Address - Street 1:1321 W DAKOTA PKWY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3807
Practice Address - Country:US
Practice Address - Phone:701-572-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR53286163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse