Provider Demographics
NPI:1992428106
Name:DAUTH, JILLEEN (LPCC)
Entity type:Individual
Prefix:
First Name:JILLEEN
Middle Name:
Last Name:DAUTH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4454 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5019
Mailing Address - Country:US
Mailing Address - Phone:952-200-4271
Mailing Address - Fax:
Practice Address - Street 1:1025 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1449
Practice Address - Country:US
Practice Address - Phone:612-338-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03448103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist