Healthcare Provider Details

I. General information

NPI: 1972737997
Provider Name (Legal Business Name): JESSICA M CICI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 08/30/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 WINNETKA AVE N SUITE 101
CRYSTAL MN
55427
US

IV. Provider business mailing address

2960 WINNETKA AVE N SUITE 101
CRYSTAL MN
55427
US

V. Phone/Fax

Practice location:
  • Phone: 763-541-4993
  • Fax: 763-541-5324
Mailing address:
  • Phone: 763-541-4993
  • Fax: 763-541-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number53550
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: