Provider Demographics
NPI:1154019503
Name:ELVEHJEM, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ELVEHJEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 29TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1645
Mailing Address - Country:US
Mailing Address - Phone:320-424-3326
Mailing Address - Fax:
Practice Address - Street 1:37 COLLEGE AVE S
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MN
Practice Address - Zip Code:56374-2099
Practice Address - Country:US
Practice Address - Phone:320-363-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03244101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health