Provider Demographics
NPI:1114717543
Name:SUCHY, JACLYN ROSE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROSE
Last Name:SUCHY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-8807
Mailing Address - Country:US
Mailing Address - Phone:651-428-4423
Mailing Address - Fax:
Practice Address - Street 1:3490 LEXINGTON AVE N STE 205
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8044
Practice Address - Country:US
Practice Address - Phone:651-486-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional