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General NPI Number Information
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NPI Number | 1164923843
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Entity Type | Organization
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Legal Business Name | IMPACT PSYCHOLOGY PLLC
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Dates
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Enumeration Date | 02/27/2018
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Last Update Date | 02/27/2018
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Provider Practice Location Address
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Address Line | 724 BIELENBERG DRIVE SUITE 4
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City | WOODBURY
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State | MN
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Zip | 55125-5512
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Country | US
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Telephone | 651-204-4034
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Fax |
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Provider Business Mailing Address
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Address Line | 6958 W 84TH ST
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City | MINNEAPOLIS
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State | MN
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Zip | 55438-1159
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Country | US
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Telephone | 651-235-5170
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. JASON ECKERMAN
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Credential | PSYD
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Telephone | 651-204-4034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | LP5825
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License Number State | MN
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