Provider Demographics
NPI:1811540503
Name:AMYS, JACLYN (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:AMYS
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 HICKORY HILL DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2410
Mailing Address - Country:US
Mailing Address - Phone:218-393-1328
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 450
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1460
Practice Address - Country:US
Practice Address - Phone:952-368-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health