Provider Demographics
NPI:1902215064
Name:ARCHBOLD, JESSICA JAYNE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JAYNE
Last Name:ARCHBOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1225
Mailing Address - Country:US
Mailing Address - Phone:602-501-0358
Mailing Address - Fax:
Practice Address - Street 1:2828 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1573
Practice Address - Country:US
Practice Address - Phone:612-871-7639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-03
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN221051-3163W00000X
TNRN0000178937163W00000X
TN103434367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse