Provider Demographics
NPI:1932372224
Name:KISH, JENNIFER DEBRA (GNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DEBRA
Last Name:KISH
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 JUBERT TRL
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-3707
Mailing Address - Country:US
Mailing Address - Phone:952-412-7019
Mailing Address - Fax:
Practice Address - Street 1:8307 KIMBALL DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-2127
Practice Address - Country:US
Practice Address - Phone:612-324-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1722659363LG0600X
MNCNP0023363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology