Provider Demographics
NPI:1568918126
Name:MALLORY LAGRAVES, JAIME-LYNN (MSED, LPCC)
Entity Type:Individual
Prefix:
First Name:JAIME-LYNN
Middle Name:
Last Name:MALLORY LAGRAVES
Suffix:
Gender:F
Credentials:MSED, LPCC
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:LYNN
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-302-8698
Practice Address - Street 1:40 11TH ST
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1817
Practice Address - Country:US
Practice Address - Phone:218-879-4559
Practice Address - Fax:218-879-0282
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1274101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568918126Medicaid
MN1568918126Medicaid