Provider Demographics
NPI:1629480850
Name:ROFF, JACQUELINE FAYE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:FAYE
Last Name:ROFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 FRANCE AVE S STE 400
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2130
Mailing Address - Country:US
Mailing Address - Phone:952-920-2070
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S STE 400
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2130
Practice Address - Country:US
Practice Address - Phone:952-920-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13705363A00000X
MN23152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer