Provider Demographics
NPI:1093124166
Name:JENNIFER GROSSMAN-CHINBURG, LICSW, PLLC
Entity Type:Organization
Organization Name:JENNIFER GROSSMAN-CHINBURG, LICSW, PLLC
Other - Org Name:JENN GROSSMAN-CHINBURG, LICSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:N
Authorized Official - Last Name:GROSSMAN-CHINBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:507-766-0158
Mailing Address - Street 1:2616 17TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-5116
Mailing Address - Country:US
Mailing Address - Phone:507-766-0158
Mailing Address - Fax:
Practice Address - Street 1:1809 S BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6567
Practice Address - Country:US
Practice Address - Phone:701-833-2085
Practice Address - Fax:701-837-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND43981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty