Healthcare Provider Details

I. General information

NPI: 1760140180
Provider Name (Legal Business Name): JACI RAE HANNASCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACI RAE PRONK

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

507 MERCEDES DR
MARSHALL MN
56258-5497
US

V. Phone/Fax

Practice location:
  • Phone: 507-532-9661
  • Fax:
Mailing address:
  • Phone: 605-360-6046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8803
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: