Healthcare Provider Details

I. General information

NPI: 1144598806
Provider Name (Legal Business Name): JACQUELINE L SUFKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax:
Mailing address:
  • Phone: 320-252-1670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number370745
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20814
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number20814
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: