Healthcare Provider Details

I. General information

NPI: 1548972425
Provider Name (Legal Business Name): DAVID JACKSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 RAILROAD ST SE
PINE CITY MN
55063-1540
US

IV. Provider business mailing address

220 RAILROAD ST SE
PINE CITY MN
55063-1540
US

V. Phone/Fax

Practice location:
  • Phone: 320-629-7600
  • Fax:
Mailing address:
  • Phone: 320-629-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21551
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier21551
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: