Healthcare Provider Details

I. General information

NPI: 1669705638
Provider Name (Legal Business Name): JACKIE LYN MICKLEWRIGHT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SMITH AVE N STE 220
SAINT PAUL MN
55102-2459
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-8295
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5324
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: