Provider Demographics
NPI:1518989656
Name:DICELLO, JACALYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACALYN
Middle Name:
Last Name:DICELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:14000 NICOLLET AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5790
Practice Address - Country:US
Practice Address - Phone:952-428-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23731207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0702123OtherMEDICA
MN0371001OtherPREFERRED ONE
MN087288100Medicaid
MNHP10327OtherHEALTH PARTNERS
MN57F36DIOtherBLUE SHIELD
MN0702123OtherMEDICA
MN160002900Medicare PIN