Provider Demographics
NPI:1902295306
Name:HARRISON, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HARRISON
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 1:12708 WAYZATA BLVD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1916
Mailing Address - Country:US
Mailing Address - Phone:763-443-4562
Mailing Address - Fax:
Practice Address - Street 1:12708 WAYZATA BLVD
Practice Address - Street 2:SUITE 412
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1916
Practice Address - Country:US
Practice Address - Phone:763-443-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1796101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)