Healthcare Provider Details

I. General information

NPI: 1962183558
Provider Name (Legal Business Name): JESSE BEULKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 WAYZATA BLVD STE 100
MINNETONKA MN
55305-1500
US

IV. Provider business mailing address

616 14TH ST
FARMINGTON MN
55024-1783
US

V. Phone/Fax

Practice location:
  • Phone: 952-544-6806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: