Provider Demographics
NPI:1588979306
Name:JACKSON, KATRINA MARGARET (CNP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:MARGARET
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:MARGARET
Other - Last Name:CIRILLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5309
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:1580 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1127
Practice Address - Country:US
Practice Address - Phone:651-779-7978
Practice Address - Fax:651-779-7656
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285871363L00000X
OH11676363L00000X
MN2397795363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201010130Medicaid
KY7100132960Medicaid
OH3080713Medicaid
IN201010130Medicaid
OH3080713Medicaid