Provider Demographics
NPI:1093448540
Name:HJERMSTAD, MADISON VIRGINIA
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:VIRGINIA
Last Name:HJERMSTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WARREN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-0512
Mailing Address - Country:US
Mailing Address - Phone:507-630-1136
Mailing Address - Fax:
Practice Address - Street 1:1720 BASSETT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6569
Practice Address - Country:US
Practice Address - Phone:507-565-0150
Practice Address - Fax:800-513-7805
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician