Provider Demographics
NPI:1093230088
Name:ROSEBERRY, JARETT EDWARD (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JARETT
Middle Name:EDWARD
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 BLACKFOOT ST NW STE 405
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2773
Mailing Address - Country:US
Mailing Address - Phone:763-236-0888
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 400
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2776
Practice Address - Country:US
Practice Address - Phone:763-236-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3438-57103T00000X
MNLP6148103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist