Healthcare Provider Details

I. General information

NPI: 1174186738
Provider Name (Legal Business Name): JACQUELYN LEE KERKOW-DOHMEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARSCHALL RD STE 100
SHAKOPEE MN
55379-2689
US

IV. Provider business mailing address

500 MARSCHALL RD STE 300
SHAKOPEE MN
55379-2690
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-6557
  • Fax: 952-448-6047
Mailing address:
  • Phone: 952-856-3932
  • Fax: 952-448-6047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22546
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: