Provider Demographics
NPI:1760691141
Name:EVERTS, JESSIE C (MA LAMFT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:C
Last Name:EVERTS
Suffix:
Gender:F
Credentials:MA LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 MOONLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8535
Mailing Address - Country:US
Mailing Address - Phone:612-801-1188
Mailing Address - Fax:
Practice Address - Street 1:864 MOONLIGHT DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8535
Practice Address - Country:US
Practice Address - Phone:612-801-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist