Provider Demographics
NPI:1811605306
Name:CHRISTIANSON, JACQUELYN ANN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANN
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CARVER BLUFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-9516
Mailing Address - Country:US
Mailing Address - Phone:952-237-5145
Mailing Address - Fax:
Practice Address - Street 1:636 CARVER BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MN
Practice Address - Zip Code:55315-9516
Practice Address - Country:US
Practice Address - Phone:952-237-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician