Provider Demographics
NPI:1093723736
Name:PADGETT, JACKIE LYN (RN)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYN
Last Name:PADGETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 SILVER LN NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3471
Mailing Address - Country:US
Mailing Address - Phone:612-760-6515
Mailing Address - Fax:
Practice Address - Street 1:255 SMITH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2518
Practice Address - Country:US
Practice Address - Phone:651-726-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 143648-2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse