Provider Demographics
NPI:1083780829
Name:WHITESIDE, MARY JANE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:DR
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:WHITESIDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:217 PLUM ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2351
Mailing Address - Country:US
Mailing Address - Phone:651-388-4302
Mailing Address - Fax:651-385-9052
Practice Address - Street 1:217 PLUM ST
Practice Address - Street 2:SUITE 140
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2351
Practice Address - Country:US
Practice Address - Phone:651-388-4302
Practice Address - Fax:651-385-9052
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3361103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN167752OtherUCARE
MN108480OtherHEALTHPARTNERS
MN132T8WHOtherBLUECROSS BLUESHIELD(IND)
MN1027089OtherPREFERREDONE
MN132T7WHOtherBLUECROSS BLUESHIELD(GRP)
MN61-68825OtherUNITED BEHAVIORAL HEALTH
MN(NO NUMBER)OtherMMSI (MAYO)