Healthcare Provider Details

I. General information

NPI: 1336662915
Provider Name (Legal Business Name): JESSICA ANTON DOOLEY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-5372
  • Fax: 763-581-6401
Mailing address:
  • Phone: 763-520-5200
  • Fax: 763-581-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20004
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: