Basic Information
| Provider Information | |||||||||
| NPI: | 1891723847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLIPNICK | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 COUNTY ROAD 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563034872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202028949 | ||||||||
| FaxNumber: | 3202020756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 33RD ST S | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202518181 | ||||||||
| FaxNumber: | 3202516942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 11/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10000 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 332113400 | 05 | MN | MEDICAID |