Provider Demographics
NPI:1730260902
Name:JACKSON, TALIA AMO (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:TALIA
Middle Name:AMO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:TALIA
Other - Middle Name:AMO
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:424 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2059
Mailing Address - Country:US
Mailing Address - Phone:612-709-7153
Mailing Address - Fax:651-646-3959
Practice Address - Street 1:2600 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2123
Practice Address - Country:US
Practice Address - Phone:612-709-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical