Provider Demographics
NPI:1932410263
Name:FREDERICKSEN, JENNA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH
Last Name:FREDERICKSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1650 NEW BRIGHTON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 NEW BRIGHTON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1643
Practice Address - Country:US
Practice Address - Phone:612-781-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN10773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant