Provider Demographics
NPI:1972743391
Name:SAMUELSON, JACQUELINE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 PREMIER DR STE 330
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6494
Mailing Address - Country:US
Mailing Address - Phone:507-420-4681
Mailing Address - Fax:
Practice Address - Street 1:1961 PREMIER DR STE 330
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6494
Practice Address - Country:US
Practice Address - Phone:507-420-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant