Provider Demographics
NPI:1316921687
Name:LICINA, JELENA A (MD)
Entity type:Individual
Prefix:DR
First Name:JELENA
Middle Name:A
Last Name:LICINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:651-232-1123
Mailing Address - Fax:651-232-5700
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73953207R00000X
FLME 88772207R00000X
CO50835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268901400Medicaid
CO59135727Medicaid
CO029545OtherKAISER COMMERCIAL NUMBER
U2193ZMedicare ID - Type Unspecified
FL268901400Medicaid