Healthcare Provider Details

I. General information

NPI: 1407924780
Provider Name (Legal Business Name): JAMES AVENUE PSYCHOLOGICAL CONSULTATION, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 JAMES AVE S
MINNEAPOLIS MN
55408-2533
US

IV. Provider business mailing address

3220 HAMPSHIRE AVE N
CRYSTAL MN
55427-2249
US

V. Phone/Fax

Practice location:
  • Phone: 612-227-2829
  • Fax: 612-377-7501
Mailing address:
  • Phone: 612-227-2829
  • Fax: 612-377-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP3550
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. MELISSA MISSY BLAIR
Title or Position: PRESIDENT
Credential: PHD
Phone: 612-227-2829