Provider Demographics
NPI:1548558257
Name:SULLIVAN, JENNA (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 CENTRAL AVENUE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-379-1119
Mailing Address - Fax:
Practice Address - Street 1:327 CENTRAL AVENUE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414
Practice Address - Country:US
Practice Address - Phone:612-379-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1098277OtherNCCPA CERTIFICATE
MN10943OtherMN BOARD OF MEDICAL PRACTICE LICENSE