Provider Demographics
NPI:1134639933
Name:LUGINBILL, JACKLYN ELENA (BA)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ELENA
Last Name:LUGINBILL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 W 15TH ST APT 206
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2424
Mailing Address - Country:US
Mailing Address - Phone:951-533-2412
Mailing Address - Fax:
Practice Address - Street 1:18 W 15TH ST APT 206
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2424
Practice Address - Country:US
Practice Address - Phone:951-533-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
MNA507480700171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA405488800OtherSCOTT COUNTY
MNA288173200OtherHENNEPIN COUNTY
MNA507480700OtherDHS