Provider Demographics
NPI:1689034175
Name:WU, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 210
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5831
Practice Address - Country:US
Practice Address - Phone:612-615-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist