Provider Demographics
NPI:1679132989
Name:MIRR, JACQUELYN FAITH (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:FAITH
Last Name:MIRR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:FAITH
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1687 WOODLANE DR STE 101&102
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3045
Mailing Address - Country:US
Mailing Address - Phone:651-600-3035
Mailing Address - Fax:651-348-8783
Practice Address - Street 1:1687 WOODLANE DR STE AND102
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3045
Practice Address - Country:US
Practice Address - Phone:651-600-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN74576207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty