Healthcare Provider Details

I. General information

NPI: 1154019503
Provider Name (Legal Business Name): JACKIE ELVEHJEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 25TH AVE S STE 201
SAINT CLOUD MN
56301-4818
US

IV. Provider business mailing address

1221 29TH AVE N
SAINT CLOUD MN
56303-1645
US

V. Phone/Fax

Practice location:
  • Phone: 612-682-5652
  • Fax:
Mailing address:
  • Phone: 320-424-3326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC03244
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: