Basic Information
| Provider Information | |||||||||
| NPI: | 1588979306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CIRILLI | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | MARGARET | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025309 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517797978 | ||||||||
| FaxNumber: | 6517797656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704285871 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 11676 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 2397795 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201010130 | 05 | IN | MEDICAID | 7100132960 | 05 | KY | MEDICAID | 3080713 | 05 | OH | MEDICAID |