Healthcare Provider Details

I. General information

NPI: 1730483975
Provider Name (Legal Business Name): JAKE DARREN PIERCE-WALSH MSW, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE DARREN WALSH MSW, LICSW

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 6TH AVE E
DULUTH MN
55805-1952
US

IV. Provider business mailing address

302 W SUPERIOR ST STE 508
DULUTH MN
55802-5115
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7000
  • Fax:
Mailing address:
  • Phone: 218-249-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19586
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: