Provider Demographics
NPI:1760140180
Name:HANNASCH, JACI RAE (CNP)
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:RAE
Last Name:HANNASCH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JACI
Other - Middle Name:RAE
Other - Last Name:PRONK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:507 MERCEDES DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-5497
Mailing Address - Country:US
Mailing Address - Phone:605-360-6046
Mailing Address - Fax:
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-532-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner