Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | D8462 | MN |
NPI | 1083777122 |
---|---|
Provider Name | Dr. Jane Mary Hermes-Jensen |
First Address | Maplewood, MN 55109-4567 |
Second Address | Woodbury, MN 55125-3926 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 08/07/2007 |