1700043734 NPI number — MRS. JACALYN NELSON RPH

Table of content: MRS. JACALYN NELSON RPH (NPI 1700043734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700043734 NPI number — MRS. JACALYN NELSON RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
JACALYN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1700043734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10400 KADLER AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55362-8165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-389-3111
Provider Business Mailing Address Fax Number:
763-389-1621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 NORTHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55371-2168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-389-3111
Provider Business Practice Location Address Fax Number:
763-389-1621
Provider Enumeration Date:
05/19/2008

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: 183500000X , with the licence number:  1160693 , 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: 132460000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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