Provider Demographics
NPI:1578700191
Name:WILSON, JINA KAY-LEBAKKEN (MS,LMFT)
Entity Type:Individual
Prefix:
First Name:JINA
Middle Name:KAY-LEBAKKEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20083 EXPLORER AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8992
Mailing Address - Country:US
Mailing Address - Phone:651-261-6330
Mailing Address - Fax:612-440-2209
Practice Address - Street 1:20083 EXPLORER AVE N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8992
Practice Address - Country:US
Practice Address - Phone:651-261-6330
Practice Address - Fax:612-440-2209
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1079106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist