Healthcare Provider Details

I. General information

NPI: 1194413658
Provider Name (Legal Business Name): MARGURITE CAMILLE JAKUBIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE # AO-102
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE # AO-102
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-3113
  • Fax: 612-626-6601
Mailing address:
  • Phone: 612-624-3113
  • Fax: 612-626-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82663
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: