Healthcare Provider Details

I. General information

NPI: 1477332443
Provider Name (Legal Business Name): JESSICA COBURN MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 NW 3RD ST
GRAND RAPIDS MN
55744-2135
US

IV. Provider business mailing address

41332 COUNTY ROAD 603
NASHWAUK MN
55769-4149
US

V. Phone/Fax

Practice location:
  • Phone: 218-328-3214
  • Fax:
Mailing address:
  • Phone: 218-966-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number30094
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: