Basic Information
| Provider Information | |||||||||
| NPI: | 1023086568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 2805 CAMPUS DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635197440 | ||||||||
| FaxNumber: | 7635197445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R128366-4 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1032598 | 01 | MN | PREFERREDONE | OTHER | 151404 | 01 | MN | UCARE MN | OTHER | 737611100 | 05 | MN | MEDICAID | 404934900 | 05 | MD | MEDICAID | 41184100 | 05 | WI | MEDICAID | 0105787 | 01 | MN | MEDICA | OTHER | 67B81CO | 01 | MN | BLUE CROSS BLUE SHIELD MN | OTHER | HP32641 | 01 | MN | HEALTHPARTNERS | OTHER | 1241627 | 01 | MN | AMERICA'S PPO | OTHER |