Provider Demographics
NPI:1669286654
Name:MATTSON, JACQUELINE S (STUDENT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:MATTSON
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:S
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STUDENT
Mailing Address - Street 1:20674 140TH ST
Mailing Address - Street 2:
Mailing Address - City:VERNDALE
Mailing Address - State:MN
Mailing Address - Zip Code:56481-2208
Mailing Address - Country:US
Mailing Address - Phone:218-639-5492
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program