Provider Demographics
NPI:1871392803
Name:TIRIMBA, JACKLINE SARANGE
Entity type:Individual
Prefix:
First Name:JACKLINE
Middle Name:SARANGE
Last Name:TIRIMBA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 RHINESTONE ST NW APT 127
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4996
Mailing Address - Country:US
Mailing Address - Phone:612-203-8038
Mailing Address - Fax:
Practice Address - Street 1:1200 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4199
Practice Address - Country:US
Practice Address - Phone:612-203-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health