MEDICARE: JACQUELINE RUTH SMALLEY LPCC, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	CC02558	MN

General Provider Information

NPI Number	:	1124632468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RUTH SMALLEY LPCC, LADC

Provider Business Mailing Address
First Line	:	1800 CHICAGO AVE STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2592
Country	:	US
Telephone Number	:	651-485-8845
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 CHICAGO AVE STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2592
Country	:	US
Telephone Number	:	612-695-4885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	10/28/2024

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