Provider Demographics
NPI:1578801346
Name:HAWKINSON, JACKIE LYNN (SPTA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:HAWKINSON
Suffix:
Gender:F
Credentials:SPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2425
Mailing Address - Country:US
Mailing Address - Phone:612-578-0502
Mailing Address - Fax:
Practice Address - Street 1:6008 GOODRICH AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2425
Practice Address - Country:US
Practice Address - Phone:612-578-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNG087026331215390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program