MEDICARE: JACOB NICHOLAUS MARUSKA LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3957	MN

General Provider Information

NPI Number	:	1124713037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB NICHOLAUS MARUSKA LPCC

Provider Business Mailing Address
First Line	:	5637 BROOKLYN BLVD
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-3061
Country	:	US
Telephone Number	:	612-232-1073
Fax Number	:

Provider Business Practice Location Address
First Line	:	5637 BROOKLYN BLVD
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-3061
Country	:	US
Telephone Number	:	612-232-1073
Fax Number	:	763-951-2132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	04/06/2023

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