Provider Demographics
NPI:1023086568
Name:COLLINS, JACKIE L (CNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5311
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:2805 CAMPUS DR STE 105
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2677
Practice Address - Country:US
Practice Address - Phone:763-519-7440
Practice Address - Fax:763-519-7445
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR128366-4363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1032598OtherPREFERREDONE
MN151404OtherUCARE MN
MN737611100Medicaid
MD404934900Medicaid
WI41184100Medicaid
MN0105787OtherMEDICA
MN67B81COOtherBLUE CROSS BLUE SHIELD MN
MNHP32641OtherHEALTHPARTNERS
MN1241627OtherAMERICA'S PPO
MD404934900Medicaid
MN500002250Medicare ID - Type UnspecifiedMEDICARE