Provider Demographics
NPI:1447694013
Name:CONLEY, JACQUELYN LORRAINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LORRAINE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-847-4029
Mailing Address - Fax:
Practice Address - Street 1:1200 CHASKA CREEK WAY STE 200
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2749
Practice Address - Country:US
Practice Address - Phone:952-856-1046
Practice Address - Fax:952-856-1049
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine