NPIMap

Individual provider Active NPI

Jennifer A Prom, PAC

  • Physician Assistant
  • Duluth, MN
National Provider Identifier
1215948781
Registry record updated Dec 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
10142 Issued in MN
Practice address
619 W Central Entrance
Duluth, MN 55811-5448
Phone
(218) 249-4987
Fax
(218) 249-4989
NPI assigned
Aug 10, 2006
Last updated
Dec 16, 2020By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 4215 WI
Physician Assistant 363A00000X 10142 MN Primary

Addresses

Primary practice location

619 W Central Entrance
Duluth, MN 55811-5448

Mailing address

619 W Central Entrance
Duluth, MN 55811-5448
Phone (218) 249-4987

Other practice location 1

109 N 28th St E
Superior, WI 54880-6548
Phone (715) 395-3950

Other identifiers 1

IdentifierTypeStateIssuer
157938000MedicaidMN

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address him@slk.direct.slhduluth.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN, WI2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20060503000634 MN Practitioner - Physician Assistant 1658381710 Reassigns benefits to 1 organization
I20190312003071 WI Practitioner - Physician Assistant 1658381710 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
St. Luke's Hospital of DuluthGroup PAC ID 7113834839, 409 clinicians

Practice addresses (Care Compare)

1011 E 1St St
Duluth, MN 55805-2242
Phone (218) 249-7000

1015 E 1St St
Duluth, MN 55805-2242
Phone (218) 249-7860

4190 Loberg Ave
Duluth, MN 55811-2652
Phone (218) 249-4600

4702 Grand Ave
Duluth, MN 55807-2742
Phone (218) 249-6800

619 W Central Entrance
Duluth, MN 55811-5448
Phone (218) 249-4987

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
10142MNMDDentist
4215WIMDOccupational Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
St. Luke's Hospital of Duluth CurrentSince Feb 9, 2015 Accepting new patients
St. Luke's Hospital of Duluth CurrentSince Jan 20, 2019 Accepting new patients
St. Luke's Hospital of Duluth Current Accepting new patients
St. Luke's Hospital of Duluth CurrentSince Feb 9, 2015 Accepting new patients
St. Luke's Hospital of Duluth Past Accepting new patients

Locations

29980 Network Pl
Chicago, IL 60673

1011 E 1st St
Duluth, MN 55805
Phone (218) 249-6111

1015 E 1st St
Duluth, MN 55805
Phone (218) 249-7860

4702 Grand Ave
Duluth, MN 55807
Phone (218) 249-6800

619 W Central Entrance
Duluth, MN 55811
Phone (218) 249-4987

915 E 1st St
Duluth, MN 55805
Phone (218) 249-5352

4190 Loberg Ave
Hermantown, MN 55811
Phone (218) 249-4600

109 N 28th St E
Superior, WI 54880
Phone (715) 395-3900

Interoperability endpoints

  • Direct secure messaging: jprom237279@direct.aspirus.org

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 26

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155168000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1608076800000",
    "number": "1215948781",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "619 W CENTRAL ENTRANCE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558115448",
            "telephone_number": "218-249-4987",
            "fax_number": "218-249-4989"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "619 W CENTRAL ENTRANCE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558115448",
            "telephone_number": "218-249-4987",
            "fax_number": "218-249-4989"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "109 N 28th St E",
            "address_purpose": "LOCATION",
            "city": "Superior",
            "state": "WI",
            "postal_code": "548806548",
            "country_code": "US",
            "telephone_number": "715-395-3950",
            "fax_number": "715-395-3955",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PROM",
        "first_name": "JENNIFER",
        "middle_name": "A",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-10",
        "last_updated": "2020-12-16",
        "certification_date": "2020-12-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WI",
            "license": "4215",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "10142",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "157938000",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "him@slk.direct.slhduluth.com",
            "affiliation": "N",
            "address_1": "619 W Central Entrance",
            "city": "Duluth",
            "state": "MN",
            "country_code": "US",
            "postal_code": "558115448",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.