Healthcare Provider Details

I. General information

NPI: 1063715431
Provider Name (Legal Business Name): JAYNE LOKKEN PH. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR VA MEDICAL CENTER
ST. CLOUD MN
56303
US

IV. Provider business mailing address

134 RIVERSIDE DR NE
SAINT CLOUD MN
56304-0436
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax:
Mailing address:
  • Phone: 762-258-7066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4377
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2153-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: