Provider Demographics
NPI:1427206036
Name:JESSIE, JACQUELINE ALLEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ALLEN
Last Name:JESSIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MICHELLE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8499 KARLSTAD CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7384
Mailing Address - Country:US
Mailing Address - Phone:281-248-1383
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:478-538-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX647853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F21691OtherMEDICARE IDENTIFICATION NUMBER