Provider Demographics
NPI:1568464352
Name:MCCLINTOCK, JANE M (CRNA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12547 ZUMBROTA ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6171
Mailing Address - Country:US
Mailing Address - Phone:612-272-4255
Mailing Address - Fax:
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-8049
Practice Address - Fax:651-254-8049
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 123540-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN549S6JAOtherBCBSMN
MN590843400Medicaid
MN430004437Medicare PIN