Provider Demographics
NPI:1942758602
Name:TRACE, JENNIFER ELAINE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:TRACE
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5309
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 210
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2281
Practice Address - Country:US
Practice Address - Phone:952-928-2900
Practice Address - Fax:952-928-2944
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2023-01-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN12200363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical