=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396496311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNETTE MASSEY LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1983 SLOAN PL STE 15
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55117-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-888-2463
-----------------------------------------------------
Fax | 651-340-2163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1983 SLOAN PL STE 15
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55117-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-340-1373
-----------------------------------------------------
Fax | 651-340-2163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 305290
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------