Provider Demographics
NPI:1326761842
Name:MORIASI, JACKLINE MONYANGI (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JACKLINE
Middle Name:MONYANGI
Last Name:MORIASI
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:JACKLINE
Other - Middle Name:MONYANGI
Other - Last Name:RAINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 350
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2155
Practice Address - Country:US
Practice Address - Phone:763-503-8560
Practice Address - Fax:763-503-8563
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10108363LP0808X
GARN312890363LP0808X
MN1699478163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse