Provider Demographics
NPI:1891361374
Name:LETOURNEAU, JACQUELINE MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:LETOURNEAU
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 30TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-8361
Mailing Address - Country:US
Mailing Address - Phone:507-358-5525
Mailing Address - Fax:
Practice Address - Street 1:25 16TH ST NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4158
Practice Address - Country:US
Practice Address - Phone:507-218-4773
Practice Address - Fax:651-383-4952
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305737101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)