| Modern Mojo | |
|
28 Nw 4th St Suite A Grand Rapids MN 55744-2714 | |
| (218) 999-7750 | |
| Not Available |
| Full Name | Modern Mojo |
|---|---|
| Speciality | Clinic/Center |
| Location | 28 Nw 4th St, Grand Rapids, Minnesota |
| Authorized Official Name and Position | Tonya Marie Zimmerman (OFFICE MANAGER) |
| Authorized Official Contact | 2189997750 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Modern Mojo 28 Nw 4th St Suite A Grand Rapids MN 55744-2714 Ph: (218) 999-7750 | Modern Mojo 28 Nw 4th St Suite A Grand Rapids MN 55744-2714 Ph: (218) 999-7750 |
| NPI Number | 1902344591 |
|---|---|
| Provider Enumeration Date | 02/03/2017 |
| Last Update Date | 03/08/2023 |
| Certification Date | 03/08/2023 |
| Medicare PECOS PAC ID | 1456621457 |
|---|---|
| Medicare Enrollment ID | O20170725000993 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902344591 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Tracy Ann Zimmerman-deschepper |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1457753295 PECOS PAC ID: 4183846082 Enrollment ID: I20141110000282 |
| Provider Name | Shelley A Leutschaft |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1427430735 PECOS PAC ID: 4981917002 Enrollment ID: I20150720000648 |
| Provider Name | Krista L Mcmanus |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578948428 PECOS PAC ID: 6103136726 Enrollment ID: I20151112000178 |
| Provider Name | Rebekah M Svadlenka |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1063003895 PECOS PAC ID: 9638584717 Enrollment ID: I20210223002353 |
| Provider Name | Stacie L Jorgenson-rentschler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1992474639 PECOS PAC ID: 2062805468 Enrollment ID: I20220208000598 |
| Provider Name | Lisa Renee Thielke |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1699461095 PECOS PAC ID: 7315304284 Enrollment ID: I20230608000275 |
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