Provider Demographics
NPI:1427561455
Name:JACKSON, JULIE (LPCC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 MENDOTA HEIGHTS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1289
Mailing Address - Country:US
Mailing Address - Phone:651-379-9800
Mailing Address - Fax:
Practice Address - Street 1:1385 MENDOTA HEIGHTS RD STE 200
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1289
Practice Address - Country:US
Practice Address - Phone:651-379-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCC01638OtherINSURANCE PROVIDERS
MNCC01638Medicaid