Provider Demographics
NPI:1548028053
Name:JENNISCH, SARA JOAN (MSN, CNP, AGNP-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JOAN
Last Name:JENNISCH
Suffix:
Gender:F
Credentials:MSN, CNP, AGNP-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:J
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:270 MAIN ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6788
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6788
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:651-342-1428
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11376363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care