Provider Demographics
NPI:1073963179
Name:ANDERSON, JENNIFER (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 86TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11280 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4510
Practice Address - Country:US
Practice Address - Phone:763-400-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2966106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist