Healthcare Provider Details

I. General information

NPI: 1831329564
Provider Name (Legal Business Name): PHOENIX MENTAL HEALTH, P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 NICOLLET AVE # 210
MINNEAPOLIS MN
55403-3747
US

IV. Provider business mailing address

1911 NICOLLET AVE # 210
MINNEAPOLIS MN
55403-3747
US

V. Phone/Fax

Practice location:
  • Phone: 612-501-6807
  • Fax: 866-591-9475
Mailing address:
  • Phone: 612-501-6807
  • Fax: 866-591-9475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number18233
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SHEA JONES
Title or Position: PRESIDENT
Credential:
Phone: 612-501-6807