Provider Demographics
NPI:1164923843
Name:IMPACT PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:IMPACT PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:651-204-4034
Mailing Address - Street 1:6958 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1159
Mailing Address - Country:US
Mailing Address - Phone:651-235-5170
Mailing Address - Fax:
Practice Address - Street 1:724 BIELENBERG DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5512
Practice Address - Country:US
Practice Address - Phone:651-204-4034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5825261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)