Provider Demographics
NPI:1235273624
Name:JAUSS, JACQUELYN MARIE (PHD,LP)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:MARIE
Last Name:JAUSS
Suffix:
Gender:F
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CIVIC CENTER PLZ
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7710
Mailing Address - Country:US
Mailing Address - Phone:507-385-7725
Mailing Address - Fax:507-385-0576
Practice Address - Street 1:11 CIVIC CENTER PLZ
Practice Address - Street 2:SUITE 201
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7710
Practice Address - Country:US
Practice Address - Phone:507-385-7725
Practice Address - Fax:507-385-0576
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN114895OtherUCARE
MN297G5JAOtherBLUE CROSS
MN6162621OtherUNITED BEHAVIORAL HEALTH
MN195228500Medicaid
MN6162621OtherUNITED BEHAVIORAL HEALTH