Provider Demographics
NPI:1548278203
Name:JACKS, MARY ELLEN (MS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:JACKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 QUINLAN AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MN
Mailing Address - Zip Code:55043-9527
Mailing Address - Country:US
Mailing Address - Phone:651-436-1606
Mailing Address - Fax:
Practice Address - Street 1:401 STAGELINE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7897
Practice Address - Country:US
Practice Address - Phone:715-531-6760
Practice Address - Fax:715-531-6761
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI617-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist