Provider Demographics
NPI:1174539514
Name:THACKER, JENNY L (MD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:L
Last Name:THACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7301 OHMS LN
Mailing Address - Street 2:SUITE 650
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2331
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:7301 OHMS LN
Practice Address - Street 2:SUITE 650
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2331
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ32400207P00000X
MN44616207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ80804Medicare PIN