Provider Demographics
NPI:1538964382
Name:PACK, HARRISON
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4741
Mailing Address - Country:US
Mailing Address - Phone:651-233-9062
Mailing Address - Fax:
Practice Address - Street 1:905 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4741
Practice Address - Country:US
Practice Address - Phone:651-233-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN04786101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty