Provider Demographics
NPI:1508112178
Name:PICKETT, JENNIFER NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CENTRACARE CLINIC ADULT AND PEDIATRIC UROLOGY
Mailing Address - Street 2:2351 CONNECTICUT AVENUE SOUTH #200
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2477
Mailing Address - Country:US
Mailing Address - Phone:320-259-1411
Mailing Address - Fax:320-259-8967
Practice Address - Street 1:CENTRACARE CLINIC ADULT AND PEDIATRIC UROLOGY
Practice Address - Street 2:2351 CONNECTICUT AVENUE SOUTH #200
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2477
Practice Address - Country:US
Practice Address - Phone:320-259-1411
Practice Address - Fax:320-259-8967
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11242363A00000X
MN1812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN970006726Medicare PIN