Provider Demographics
NPI:1598523110
Name:NORTHERN EDGE COUNSELING, LLC
Entity Type:Organization
Organization Name:NORTHERN EDGE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DECORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LICSW
Authorized Official - Phone:218-206-6676
Mailing Address - Street 1:394 S LAKE AVE STE 515
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2325
Mailing Address - Country:US
Mailing Address - Phone:218-206-6676
Mailing Address - Fax:
Practice Address - Street 1:394 S LAKE AVE STE 515
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2325
Practice Address - Country:US
Practice Address - Phone:218-206-6676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)