Provider Demographics
NPI:1730141946
Name:PAGENKOPF, JILL E (NNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:PAGENKOPF
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:E
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:14620 BISCAYNE WAY W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-3138
Mailing Address - Country:US
Mailing Address - Phone:651-423-5386
Mailing Address - Fax:
Practice Address - Street 1:1655 BEAM AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1163
Practice Address - Country:US
Practice Address - Phone:651-232-7831
Practice Address - Fax:651-232-7826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR095696-3363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP37969Medicare UPIN