Provider Demographics
NPI:1477039246
Name:ROOT, JACOB RUSSELL (LMFT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RUSSELL
Last Name:ROOT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E 2ND ST STE 224
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-6509
Mailing Address - Country:US
Mailing Address - Phone:651-272-9562
Mailing Address - Fax:
Practice Address - Street 1:902 E 2ND ST STE 224
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-6509
Practice Address - Country:US
Practice Address - Phone:651-272-9562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3588106H00000X
WALF60918068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist