Healthcare Provider Details

I. General information

NPI: 1417464033
Provider Name (Legal Business Name): JENNIFER LYNN URBACH MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 PHEASANT RIDGE DR NE STE 412
BLAINE MN
55449-5066
US

IV. Provider business mailing address

73 E GOLDEN LAKE RD
CIRCLE PINES MN
55014-1702
US

V. Phone/Fax

Practice location:
  • Phone: 763-703-3754
  • Fax: 763-703-3725
Mailing address:
  • Phone: 651-317-9081
  • Fax: 763-703-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1702
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: