Provider Demographics
NPI:1891865093
Name:BAKKA, JERRY CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CHARLES
Last Name:BAKKA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1807
Mailing Address - Country:US
Mailing Address - Phone:218-728-1162
Mailing Address - Fax:
Practice Address - Street 1:205 W 2ND ST
Practice Address - Street 2:SUITE 437
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1928
Practice Address - Country:US
Practice Address - Phone:218-722-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical