Basic Information
| Provider Information | |||||||||
| NPI: | 1528099553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCROSSEN | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R 104826-5 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 0221364-21 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LP0200X | 95231 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1013464 | 01 | MN | PREFERRED ONE | OTHER | 2444868 | 01 | MN | AMERICA'S PPO | OTHER | 410568 | 01 | MN | MEDICA | OTHER | 116351 | 01 | MN | UCARE | OTHER | 398524500 | 05 | MN | MEDICAID | HP17968 | 01 | MN | HEALTHPARTNERS | OTHER | 7K968MC | 01 | MN | BCBS OF MN | OTHER | 36018300 | 05 | WI | MEDICAID |