Healthcare Provider Details

I. General information

NPI: 1477112316
Provider Name (Legal Business Name): JESSICA MCCLURE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 130
COON RAPIDS MN
55433-2583
US

IV. Provider business mailing address

PO BOX 206
MINNEAPOLIS MN
55480-0206
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-9000
  • Fax: 763-236-9010
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14348
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: