Provider Demographics
NPI:1235810748
Name:PAULSON, JACK ANDREW
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ANDREW
Last Name:PAULSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 ALDRICH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4149
Mailing Address - Country:US
Mailing Address - Phone:920-393-8320
Mailing Address - Fax:844-440-2336
Practice Address - Street 1:3501 ALDRICH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4149
Practice Address - Country:US
Practice Address - Phone:920-393-8320
Practice Address - Fax:844-440-2336
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician