Provider Demographics
NPI:1699108209
Name:JACKSON, KATHLEEN ADELE (AG-ACNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ADELE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 LOGAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1018
Mailing Address - Country:US
Mailing Address - Phone:612-963-8189
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY AVE W FL 6
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3727
Practice Address - Country:US
Practice Address - Phone:651-232-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-169854-7363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care