Healthcare Provider Details

I. General information

NPI: 1760965156
Provider Name (Legal Business Name): JENNIFER ANN GULLICKSON MS, LPCC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN PETERSEN

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 1ST ST
MORRIS MN
56267-1408
US

IV. Provider business mailing address

400 E 1ST ST
MORRIS MN
56267-1408
US

V. Phone/Fax

Practice location:
  • Phone: 320-589-1313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01875
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC01875
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCC01875
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: