Provider Demographics
NPI:1891403135
Name:JACKAI, AGNES LIMUNGA (APRN, CNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:LIMUNGA
Last Name:JACKAI
Suffix:
Gender:F
Credentials:APRN, CNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12125 VERMILLION ST NE UNIT E
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5678
Mailing Address - Country:US
Mailing Address - Phone:612-598-3937
Mailing Address - Fax:
Practice Address - Street 1:12125 VERMILLION ST NE UNIT E
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5678
Practice Address - Country:US
Practice Address - Phone:612-598-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPENDING363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health