Healthcare Provider Details

I. General information

NPI: 1336026806
Provider Name (Legal Business Name): JAYMIE MARK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 94TH AVE N
BROOKLYN PARK MN
55443-1992
US

IV. Provider business mailing address

109 MISSISSIPPI DR
MONTICELLO MN
55362-9386
US

V. Phone/Fax

Practice location:
  • Phone: 763-762-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13241
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: