Provider Demographics
NPI:1669669396
Name:STEWART, JACQUELINE SUE (CPNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:STEWART
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3625
Mailing Address - Fax:218-786-3060
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-3625
Practice Address - Fax:218-786-3060
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1440999363LP0200X
WI158197-030363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500007291Medicare PIN
VAQ56729Medicare UPIN