Healthcare Provider Details

I. General information

NPI: 1063323350
Provider Name (Legal Business Name): THE CENTER FOR NEUROCOMPLEXITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 JENKS AVE
SAINT PAUL MN
55106-3113
US

IV. Provider business mailing address

701 JENKS AVE
SAINT PAUL MN
55106-3113
US

V. Phone/Fax

Practice location:
  • Phone: 479-422-1972
  • Fax:
Mailing address:
  • Phone: 479-422-1972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JESSICA PERRY
Title or Position: OWNER
Credential: LCSW
Phone: 479-422-1972