Basic Information
| Provider Information | |||||||||
| NPI: | 1700083680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERRICK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 50807 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PH0002X | 50807 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | 2086H0002X | 50807 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | Hospice and Palliative Medicine |
No ID Information.