Provider Demographics
NPI:1801807235
Name:STEVENS, JACKIE DEE (RN, CNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:DEE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59516 390TH AVE
Mailing Address - Street 2:
Mailing Address - City:ZUMBRO FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55991-5161
Mailing Address - Country:US
Mailing Address - Phone:507-242-6242
Mailing Address - Fax:507-398-9086
Practice Address - Street 1:59516 390TH AVE
Practice Address - Street 2:
Practice Address - City:ZUMBRO FALLS
Practice Address - State:MN
Practice Address - Zip Code:55991-5161
Practice Address - Country:US
Practice Address - Phone:507-242-6242
Practice Address - Fax:507-398-9086
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR132984-5363LG0600X
MNCNP3637363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5150779-00Medicaid
MN500007586Medicare PIN