MEDICARE: JESSICA MARIE BACKOWSKI

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	101YM0800X	Mental Health Counselor	1035	MN
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	303507	MN

General Provider Information

NPI Number	:	1427424241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MARIE BACKOWSKI

Provider Business Mailing Address
First Line	:	3460 WASHINGTON DR STE 110
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-4301
Country	:	US
Telephone Number	:	651-314-3502
Fax Number	:

Provider Business Practice Location Address
First Line	:	3460 WASHINGTON DR STE 110
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-4301
Country	:	US
Telephone Number	:	651-314-3502
Fax Number	:

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

Provider Enumeration Date	:	08/16/2015
Last Update Date	:	05/13/2024

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Directions to “ JESSICA MARIE BACKOWSKI ” Practice Location

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