MEDICARE: JACKIE LYNN HAWKINSON SPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	G087026331215	MN

General Provider Information

NPI Number	:	1578801346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE LYNN HAWKINSON SPTA

Provider Business Mailing Address
First Line	:	6008 GOODRICH AVE
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-2425
Country	:	US
Telephone Number	:	612-578-0502
Fax Number	:

Provider Business Practice Location Address
First Line	:	6008 GOODRICH AVE
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-2425
Country	:	US
Telephone Number	:	612-578-0502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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