Provider Demographics
NPI:1235016106
Name:SUPPORTIVE CHANGE COUNSELING & CONSULTING
Entity type:Organization
Organization Name:SUPPORTIVE CHANGE COUNSELING & CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:612-367-7287
Mailing Address - Street 1:202 N CEDAR AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2306
Mailing Address - Country:US
Mailing Address - Phone:612-367-7287
Mailing Address - Fax:
Practice Address - Street 1:2335 WOODBRIDGE ST APT 338
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4763
Practice Address - Country:US
Practice Address - Phone:612-367-7287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty