Jackie M Colaizy, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

1727 Issued in MN

Practice address

1900 Silver Lake Road NW
Suite 110
New Brighton, MN 55112

Phone

(651) 628-9566

Fax

(651) 628-0411

NPI assigned

Mar 30, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Jackie M Wilm Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1143676800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1460505600000",
    "number": "1265493167",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 SILVER LAKE ROAD NW",
            "address_2": "SUITE 110",
            "city": "NEW BRIGHTON",
            "state": "MN",
            "postal_code": "55112",
            "telephone_number": "651-379-1718",
            "fax_number": "651-379-1738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 SILVER LAKE ROAD NW",
            "address_2": "SUITE 110",
            "city": "NEW BRIGHTON",
            "state": "MN",
            "postal_code": "55112",
            "telephone_number": "651-628-9566",
            "fax_number": "651-628-0411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "COLAIZY",
        "first_name": "JACKIE",
        "middle_name": "M",
        "credential": "LICSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-03-30",
        "last_updated": "2016-04-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "1727",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "320477400",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACKIE",
            "last_name": "WILM",
            "middle_name": "M",
            "credential": "LICSW",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Clinical Social Worker in New Brighton, MN
• Providers in New Brighton, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.