Provider Demographics
NPI:1043404775
Name:MYRVIK, JEANNINE KATHERINE (LICSW)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:KATHERINE
Last Name:MYRVIK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2344
Mailing Address - Country:US
Mailing Address - Phone:651-241-5618
Mailing Address - Fax:651-241-7168
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-5618
Practice Address - Fax:651-241-7168
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical