Healthcare Provider Details

I. General information

NPI: 1912770553
Provider Name (Legal Business Name): JEFFREY POWELL ADC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 42ND AVE N
MINNEAPOLIS MN
55412-1711
US

IV. Provider business mailing address

1314 MARQUETTE AVE APT 2408
MINNEAPOLIS MN
55403-4133
US

V. Phone/Fax

Practice location:
  • Phone: 612-504-2047
  • Fax: 952-516-5161
Mailing address:
  • Phone: 763-290-2736
  • Fax: 952-516-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: