Healthcare Provider Details

I. General information

NPI: 1780128306
Provider Name (Legal Business Name): MELANIE NATASHA GABRIELLE HULTGREN PHD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE NATASHA GABRIELLE JACKSON

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

IV. Provider business mailing address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

V. Phone/Fax

Practice location:
  • Phone: 763-306-9057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2456
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: