=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780536318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON THERAPY COLLECTIVE (FORMERLY TALIA JACKSON PSYCHOTHERAPY SERVICES)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2026
-----------------------------------------------------
Last Update Date | 02/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 WAYZATA BLVD
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-444-1745
-----------------------------------------------------
Fax | 612-484-4557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 WAYZATA BLVD
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-444-1745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST, OWNER
-----------------------------------------------------
Name | DR. TALIA AMO JACKSON
-----------------------------------------------------
Credential | PSY.D., LP
-----------------------------------------------------
Telephone | 612-444-1745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------