NPIMap

Individual provider Active NPI

Jennifer A Lake, MD

  • Family Medicine Physician
  • White Bear Lake, MN
National Provider Identifier
1245205301
Registry record updated Dec 8, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
44657 Issued in MN
Practice address
4422 White Bear Ave N
White Bear Lake, MN 55110-3475
Phone
(651) 287-8780
Fax
(651) 287-8786
NPI assigned
Feb 22, 2006
Last updated
Dec 8, 2015By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 8, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 44657 MN Primary

Addresses

Primary practice location

4422 White Bear Ave N
White Bear Lake, MN 55110-3475

Mailing address

4422 White Bear Ave N
White Bear Lake, MN 55110-3475
Phone (651) 287-8780

Other identifiers 1

IdentifierTypeStateIssuer
179001300MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040614001551 MN Practitioner - Family Practice 8628052099 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Minnesota Medical School, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Synergy Family Physicians PAGroup PAC ID 2466631593, 6 clinicians

Practice addresses (Care Compare)

4422 White Bear Ave
White Bear Lake, MN 55110-3475

4422 White Bear Ave N
White Bear Lake, MN 55110-3475
Phone (651) 287-8780

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Forest Lake Skin and Vein Clinic Past Accepting new patients
LTC Professionals, PLLC Family Medicine PastSince Feb 1, 2011 Accepting new patients
University of Minnesota Physicians Past Accepting new patients

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Favoured Hospice, LLCDayton, MN, CCN 241617 Hospice Contracted Managing Employee May 2, 2023

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 24

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1140566400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1449532800000",
    "number": "1245205301",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4422 WHITE BEAR AVE N",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551103475",
            "telephone_number": "651-287-8780",
            "fax_number": "651-287-8786"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4422 WHITE BEAR AVE N",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551103475",
            "telephone_number": "651-287-8780",
            "fax_number": "651-287-8786"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LAKE",
        "first_name": "JENNIFER",
        "middle_name": "A",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-02-22",
        "last_updated": "2015-12-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "44657",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "179001300",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in White Bear Lake, MN

Sources for this page

Verify at the official NPI Registry.