Provider Demographics
NPI:1174186738
Name:KERKOW-DOHMEN, JACQUELYN LEE (LICSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LEE
Last Name:KERKOW-DOHMEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 FARIBAULT RD
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5780
Mailing Address - Country:US
Mailing Address - Phone:507-334-1030
Mailing Address - Fax:
Practice Address - Street 1:603 HOPE AVE
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1860
Practice Address - Country:US
Practice Address - Phone:952-492-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical