Individual
JACKIE LYN MICKLEWRIGHT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
280 SMITH AVE N STE 220, SAINT PAUL, MN 55102-2459
(651) 241-8295
Mailing address
2925 CHICAGO AVE, MINNEAPOLIS, MN 55407-1321
(612) 262-5000
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
—
—
103TC0700X
Clinical Psychologist
LP5324
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
680003191
MEDICARE PTAN
MN
Enumeration date
09/09/2009
Last updated
04/28/2026
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