Provider Demographics
NPI:1508348244
Name:TINAJERO, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TINAJERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:STREETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-2005
Practice Address - Fax:651-254-1519
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12771363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical