Healthcare Provider Details

I. General information

NPI: 1598179293
Provider Name (Legal Business Name): JACQUELINE TEMPLE KELLY HEGARTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST MC 11102F
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST MC 11102F
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3666
  • Fax: 651-254-5216
Mailing address:
  • Phone: 651-254-3666
  • Fax: 651-254-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number67298
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number62010
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: