NPIMap

Individual provider Active NPI

Jaclyn Ann Kostecka, PA-C

  • Physician Assistant
  • Brainerd, MN
National Provider Identifier
1972103000
Registry record updated Dec 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
Practice address
2014 S 6TH St
Brainerd, MN 56401-4529
Phone
(218) 829-7812
NPI assigned
Oct 28, 2020
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 6, 2022

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X Primary

Addresses

Primary practice location

2014 S 6TH St
Brainerd, MN 56401-4529

Mailing address

10516 Gull Point Rd
East Gull Lake, MN 56401-3281
Phone (320) 828-0972

Other practice location 1

24721 State Highway 15
Saint Augusta, MN 56301-9211
Phone (320) 828-0972

Other names 1

  • Jaclyn Ann Bautch Former name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220425000914 MN Practitioner - Physician Assistant 3274920103 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
St Josephs Medical CenterGroup PAC ID 8224948443, 238 clinicians

Practice addresses (Care Compare)

2014 S 6TH St
Brainerd, MN 56401-4529
Phone (218) 829-7812

2024 S 6TH St
Brainerd, MN 56401-4529
Phone (218) 828-7100

280 Barclay Ave W
Pine River, MN 56474-5197
Phone (218) 587-4416

523 N 3Rd St
Brainerd, MN 56401-3054
Phone (218) 828-7394

Hospital & facility affiliations

  • Essentia Health St Joseph'S Medical Center Hospital, Brainerd, MN, CCN 240075

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
13955MNMDPhysical Medicine & Rehabilitation Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Essentia Health Moose Lake CurrentSince Apr 25, 2022 Accepting new patients
St Joseph'S Medical Center CurrentSince Apr 10, 2022 Accepting new patients
Moose Lake Community Hospital District Current Accepting new patients
St. Joseph'S Medical Center Past Accepting new patients

Locations

523 N 3rd St
Brainerd, MN 56401
Phone (218) 828-7394

2014 S 6th St
Brainerd, MN 56401
Phone (218) 829-7812

4572 County Road 61
Moose Lake, MN 55767
Phone (218) 485-4481

280 Barclay Ave W
Pine River, MN 56474
Phone (218) 587-3222

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 and National Provider Directory roles.

Hospital & facility affiliations 10

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

NPI Registry JSON

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

{
    "created_epoch": "1603843200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670284800000",
    "number": "1972103000",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10516 GULL POINT RD",
            "city": "EAST GULL LAKE",
            "state": "MN",
            "postal_code": "564013281",
            "telephone_number": "320-828-0972"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2014 S 6TH ST",
            "city": "BRAINERD",
            "state": "MN",
            "postal_code": "564014529",
            "telephone_number": "218-829-7812"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "24721 State Highway 15",
            "address_purpose": "LOCATION",
            "city": "Saint Augusta",
            "state": "MN",
            "postal_code": "563019211",
            "country_code": "US",
            "telephone_number": "320-828-0972",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KOSTECKA",
        "first_name": "JACLYN",
        "middle_name": "ANN",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-10-28",
        "last_updated": "2022-12-06",
        "certification_date": "2022-12-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACLYN",
            "last_name": "BAUTCH",
            "middle_name": "ANN",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Brainerd, MN

Sources for this page

Verify at the official NPI Registry.