Individual
JENNIFER A LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4422 WHITE BEAR AVE N, WHITE BEAR LAKE, MN 55110-3475
(651) 287-8780
(651) 287-8786
Mailing address
4422 WHITE BEAR AVE N, WHITE BEAR LAKE, MN 55110-3475
(651) 287-8780
(651) 287-8786
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
44657
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
179001300
—
MN
Enumeration date
02/22/2006
Last updated
12/08/2015
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