Provider Demographics
NPI:1891403135
Name:JACKAI, AGNES LIMUNGA (APRN, CNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:LIMUNGA
Last Name:JACKAI
Suffix:
Gender:F
Credentials:APRN, CNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 93RD LN NE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4432
Mailing Address - Country:US
Mailing Address - Phone:612-598-3937
Mailing Address - Fax:
Practice Address - Street 1:1521 93RD LN NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4432
Practice Address - Country:US
Practice Address - Phone:612-598-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10001363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health