Provider Demographics
NPI:1881020527
Name:KELLY-FADDLER, JACQUELINE (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KELLY-FADDLER
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FADDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 4TH ST S STE 201
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-4754
Mailing Address - Country:US
Mailing Address - Phone:763-482-1185
Mailing Address - Fax:
Practice Address - Street 1:501 4TH ST S STE 201
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-4754
Practice Address - Country:US
Practice Address - Phone:763-498-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881020527Medicaid