Provider Demographics
NPI:1649357112
Name:BORK, JAYME A (DO)
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:A
Last Name:BORK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AMRTC 3301 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4516
Mailing Address - Country:US
Mailing Address - Phone:218-340-4308
Mailing Address - Fax:
Practice Address - Street 1:AMRTC 3301 7TH AVE N
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:218-340-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN418162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN377716200Medicaid
G90448Medicare UPIN
MN377716200Medicaid