Provider Demographics
NPI:1669705638
Name:MICKLEWRIGHT, JACKIE LYN (PHD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYN
Last Name:MICKLEWRIGHT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:280 SMITH AVE N STE 220
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2459
Practice Address - Country:US
Practice Address - Phone:651-241-8295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680003191OtherMEDICARE PTAN
MN680003191OtherMEDICARE PTAN