Provider Demographics
NPI:1871316398
Name:TOLLEFSON, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TOLLEFSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BERLIN AVE S
Mailing Address - Street 2:
Mailing Address - City:HERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:56248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 BERLIN AVE S
Practice Address - Street 2:
Practice Address - City:HERMAN
Practice Address - State:MN
Practice Address - Zip Code:56248
Practice Address - Country:US
Practice Address - Phone:320-304-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC807691171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor