Healthcare Provider Details

I. General information

NPI: 1538916747
Provider Name (Legal Business Name): JACKLYN LUGINBILL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W 15TH ST APT 206
MINNEAPOLIS MN
55403-2424
US

IV. Provider business mailing address

18 W 15TH ST APT 206
MINNEAPOLIS MN
55403-2424
US

V. Phone/Fax

Practice location:
  • Phone: 951-533-2412
  • Fax:
Mailing address:
  • Phone: 612-599-0582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JACKLYN ELENA LUGINBILL
Title or Position: OWNER
Credential: BA
Phone: 612-599-0582