Provider Demographics
NPI:1942275235
Name:ZACZKOWSKI, JEANETTE L (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:L
Last Name:ZACZKOWSKI
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:1811 WEIR DRIVE
Practice Address - Street 2:SUITE 355 MAIL STOP 13701A
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2273
Practice Address - Country:US
Practice Address - Phone:651-730-6151
Practice Address - Fax:651-730-1700
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN130801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN924609600Medicaid
MN924609600Medicaid