MEDICARE: DR. TALIA AMO JACKSON PSYD, LP

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	103T00000X	Psychologist	LP4738	MN
2	103TC0700X	Clinical Psychologist	LP4738	MN

General Provider Information

NPI Number	:	1730260902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TALIA AMO JACKSON PSYD, LP

Provider Business Mailing Address
First Line	:	2600 WAYZATA BLVD
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2123
Country	:	US
Telephone Number	:	612-444-1745
Fax Number	:	612-484-4557

Provider Business Practice Location Address
First Line	:	2600 WAYZATA BLVD N
Second Line	:
City	:	MPLS
State	:	MN
Zip	:	55405-2123
Country	:	US
Telephone Number	:	612-444-1745
Fax Number	:

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	02/12/2026

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