Provider Demographics
NPI:1801242284
Name:JACKSON, MARA ANN KLIPFEL (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:ANN KLIPFEL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:ANN
Other - Last Name:KLIPFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 HUNDERTMARK RD STE 220
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1197
Mailing Address - Country:US
Mailing Address - Phone:952-448-2050
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 220
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1197
Practice Address - Country:US
Practice Address - Phone:952-448-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MN15232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer