Provider Demographics
NPI:1285187013
Name:DOUGHTY, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9644
Mailing Address - Country:US
Mailing Address - Phone:612-240-6597
Mailing Address - Fax:
Practice Address - Street 1:1725 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MAPLE PLAIN
Practice Address - State:MN
Practice Address - Zip Code:55359-9644
Practice Address - Country:US
Practice Address - Phone:612-240-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health