Provider Demographics
NPI:1467965624
Name:JACKOWELL, HEATHER SARITA (LPCC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SARITA
Last Name:JACKOWELL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:S
Other - Last Name:CAMERON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:44 GOOD COUNSEL DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6599
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2079101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional