Provider Demographics
NPI:1710292321
Name:COUSINS, JENNIFER ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:COUSINS
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 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-625-5971
Practice Address - Street 1:1431 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-386-6600
Practice Address - Fax:507-625-5971
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1710292321OtherBCBS OF MN
MN1710292321OtherMMSI
MN1710292321OtherUCARE
MN1710292321OtherPRIME WEST
MN1710292321OtherPREFERRED ONE
MN1710292321Medicaid
MN1710292321OtherPRIME WEST