Healthcare Provider Details

I. General information

NPI: 1477387801
Provider Name (Legal Business Name): JESSICA ROSE MCRAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 THOMPSON AVE E STE 150
WEST ST PAUL MN
55118-3238
US

IV. Provider business mailing address

149 THOMPSON AVE E STE 150
WEST ST PAUL MN
55118-3238
US

V. Phone/Fax

Practice location:
  • Phone: 651-450-0860
  • Fax: 651-450-0759
Mailing address:
  • Phone: 651-450-0860
  • Fax: 651-450-0759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33049
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: