Provider Demographics
NPI:1053584789
Name:SULLIVAN, JENNIFER MAE (WHNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2774
Practice Address - Country:US
Practice Address - Phone:763-786-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1564338363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1053584789Medicare PIN