MEDICARE: MR. JEFFREY POWELL ADC-T

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	104100000X	Social Worker
3	171400000X	Health & Wellness Coach
4	177F00000X	Lodging Provider
5	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1912770553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY POWELL ADC-T

Provider Business Mailing Address
First Line	:	1314 MARQUETTE AVE APT 2408
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-4133
Country	:	US
Telephone Number	:	763-290-2736
Fax Number	:	952-516-5161

Provider Business Practice Location Address
First Line	:	705 42ND AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1711
Country	:	US
Telephone Number	:	612-504-2047
Fax Number	:	952-516-5161

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

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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