Provider Demographics
NPI:1073269841
Name:BAKKEN, JESSICA ANN (LADC, LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:LADC, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13503 EVELETH WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5706
Mailing Address - Country:US
Mailing Address - Phone:507-318-9806
Mailing Address - Fax:
Practice Address - Street 1:13503 EVELETH WAY
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5706
Practice Address - Country:US
Practice Address - Phone:507-318-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN253531041C0700X
MN302693101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical