Provider Demographics
NPI:1790274959
Name:WOOD, JACKIE MARIE (LPCC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:WOOD
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3810
Mailing Address - Country:US
Mailing Address - Phone:507-625-7660
Mailing Address - Fax:507-625-8998
Practice Address - Street 1:710 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3810
Practice Address - Country:US
Practice Address - Phone:507-625-7660
Practice Address - Fax:507-625-8998
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCC01773OtherLICENSED PROFESSIONAL CLINICAL COUNSELOR