Provider Demographics
NPI:1912329228
Name:JERDE, TALEASHA
Entity Type:Individual
Prefix:
First Name:TALEASHA
Middle Name:
Last Name:JERDE
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 1:1236 FARRELL ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1236 FARRELL ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55119-3175
Practice Address - Country:US
Practice Address - Phone:612-454-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1614492471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography