Provider Demographics
NPI:1235958646
Name:LUSK, JACOB CHARLES (LPCC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CHARLES
Last Name:LUSK
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 VICTORIA ST N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4444
Mailing Address - Country:US
Mailing Address - Phone:218-839-3572
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:218-839-3572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional