Provider Demographics
NPI:1215569181
Name:HANSON-HIETALA, JACQUELYN KAYE (LGSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:KAYE
Last Name:HANSON-HIETALA
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5380 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-9732
Mailing Address - Country:US
Mailing Address - Phone:218-590-1178
Mailing Address - Fax:218-481-7405
Practice Address - Street 1:205 W 2ND ST STE 300
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1928
Practice Address - Country:US
Practice Address - Phone:218-590-1178
Practice Address - Fax:218-481-7405
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN267681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical