Healthcare Provider Details

I. General information

NPI: 1518989656
Provider Name (Legal Business Name): JACALYN DICELLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 NICOLLET AVE SUITE 100
BURNSVILLE MN
55337-5790
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-0200
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number23731
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: