Basic Information
| Provider Information | |||||||||
| NPI: | 1730260902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TALIA | ||||||||
| MiddleName: | AMO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D., LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUDOLPH | ||||||||
| OtherFirstName: | TALIA | ||||||||
| OtherMiddleName: | AMO | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 424 PENN AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554052059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127097153 | ||||||||
| FaxNumber: | 6516463959 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 WAYZATA BLVD | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554052123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127097153 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP4738 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.