Healthcare Provider Details

I. General information

NPI: 1114717543
Provider Name (Legal Business Name): JACLYN ROSE SUCHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 LEXINGTON AVE N STE 205
SHOREVIEW MN
55126-8044
US

IV. Provider business mailing address

240 ROBERT DR
HASTINGS MN
55033-8807
US

V. Phone/Fax

Practice location:
  • Phone: 651-486-3808
  • Fax:
Mailing address:
  • Phone: 651-428-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4950
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: