Provider Demographics
NPI:1407924780
Name:JAMES AVENUE PSYCHOLOGICAL CONSULTATION, P.A.
Entity Type:Organization
Organization Name:JAMES AVENUE PSYCHOLOGICAL CONSULTATION, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MISSY
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-227-2829
Mailing Address - Street 1:3220 HAMPSHIRE AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2249
Mailing Address - Country:US
Mailing Address - Phone:612-227-2829
Mailing Address - Fax:612-377-7501
Practice Address - Street 1:3005 JAMES AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2533
Practice Address - Country:US
Practice Address - Phone:612-227-2829
Practice Address - Fax:612-377-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-02
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3550103TC2200X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6173818OtherMEDICA OR UBH
MN141774OtherUCARE
MN20258-11OtherBHP
MN117T6NA OR 114T7NAOtherBLUE CROSS BLUE SHIELD