Provider Demographics
NPI:1801968094
Name:BACON, JANE GALVIN (MA LP LMFT)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:GALVIN
Last Name:BACON
Suffix:
Gender:F
Credentials:MA LP LMFT
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:GALVIN
Other - Last Name:ASTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LP LMFT
Mailing Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Mailing Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-6708
Mailing Address - Country:US
Mailing Address - Phone:651-429-8544
Mailing Address - Fax:651-407-5301
Practice Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Practice Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6708
Practice Address - Country:US
Practice Address - Phone:651-429-8544
Practice Address - Fax:651-407-5301
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2821103TC0700X
MN320106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN56963BAOtherBLUE CROSS BLUE SHIELD
MN103010OtherUCARE MINNESOTA
MN30119OtherBEHAVIORAL HEALTCARE PROV