Provider Demographics
NPI:1184170383
Name:MALDONADO, JESSICA MICHELLE (CNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FREEMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082
Mailing Address - Country:US
Mailing Address - Phone:507-985-2121
Mailing Address - Fax:
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-985-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4699364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCNP4699OtherAMERICAN NURSE'S CREDENTIALING CENTER