Provider Demographics
NPI:1790003846
Name:BAKER, JAX TAYLOR (LPC)
Entity type:Individual
Prefix:
First Name:JAX
Middle Name:TAYLOR
Last Name:BAKER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 HARBOR LN N STE 1600
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5142
Mailing Address - Country:US
Mailing Address - Phone:612-924-3807
Mailing Address - Fax:
Practice Address - Street 1:5007 HARBOR LANE NORTH
Practice Address - Street 2:SUITE 1600
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447
Practice Address - Country:US
Practice Address - Phone:612-924-3807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3824101YP2500X
ARP1607091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228551719Medicaid