1023086568 NPI number — JACKIE L COLLINS CNP

Table of content: JACKIE L COLLINS CNP (NPI 1023086568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023086568 NPI number — JACKIE L COLLINS CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
JACKIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023086568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W STE 110N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-602-5311
Provider Business Mailing Address Fax Number:
651-222-6786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2805 CAMPUS DR STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-2677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-519-7440
Provider Business Practice Location Address Fax Number:
763-519-7445
Provider Enumeration Date:
03/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R128366-4 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1032598 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 151404 . This is a "UCARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 737611100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404934900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41184100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0105787 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 67B81CO . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP32641 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1241627 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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