Provider Demographics
NPI:1912122797
Name:SOUTHWICK, JENEFER JUNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENEFER
Middle Name:JUNE
Last Name:SOUTHWICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9449
Mailing Address - Country:US
Mailing Address - Phone:218-485-5050
Mailing Address - Fax:218-485-5008
Practice Address - Street 1:1000 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9449
Practice Address - Country:US
Practice Address - Phone:218-485-5050
Practice Address - Fax:218-485-5008
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7977363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7977OtherSTATE LISCENSE