Provider Demographics
NPI:1205348802
Name:HAAS, JESSICA LOUISE (LN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:HAAS
Suffix:
Gender:F
Credentials:LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 26TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3014
Mailing Address - Country:US
Mailing Address - Phone:612-964-2938
Mailing Address - Fax:
Practice Address - Street 1:3840 26TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3014
Practice Address - Country:US
Practice Address - Phone:612-964-2938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN224133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist