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General NPI Number Information
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NPI Number | 1518396647
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Entity Type | Individual
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Provider Name | LORA JAECKS
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Gender | Female
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Dates
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Enumeration Date | 11/08/2013
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Last Update Date | 11/08/2013
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Provider Practice Location Address
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Address Line | 3411 S. ST. CROIX TRAIL
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City | AFTON
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State | MN
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Zip | 55001
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Country | US
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Telephone | 651-795-9777
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Fax |
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Provider Business Mailing Address
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Address Line | 406 ROOSEVELT DR
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City | DRESSER
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State | WI
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Zip | 54009-9065
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Country | US
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Telephone | 715-966-5372
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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