Basic Information
| Provider Information | |||||||||
| NPI: | 1598874778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUONG | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6545 FRANCE AVE S STE 350 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202600 | ||||||||
| FaxNumber: | 9529202668 | ||||||||
| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVE S STE 350 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202600 | ||||||||
| FaxNumber: | 9529202668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 40310 | MN | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00263371 | 01 | MN | RAILROAD MEDICARE | OTHER | 40310 | 01 | MN | MINNESOTA LICENSE | OTHER | 151727 | 01 | MN | UCARE | OTHER | 495527700 | 05 | MN | MEDICAID | 548T8LU | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 1300021 | 01 | MN | MEDICA PRIMARY | OTHER | 34612600 | 05 | WI | MEDICAID | 960001031243 | 01 | MN | PREFERREDONE | OTHER | 1300179 | 01 | MN | MEDICA | OTHER | HP35943 | 01 | MN | HEALTHPARTNERS | OTHER |