Provider Demographics
NPI:1164433165
Name:LEBLOND, JILL RAQUEL (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:RAQUEL
Last Name:LEBLOND
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 GRAND AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3022
Mailing Address - Country:US
Mailing Address - Phone:651-287-0931
Mailing Address - Fax:651-287-0967
Practice Address - Street 1:1053 GRAND AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3022
Practice Address - Country:US
Practice Address - Phone:651-287-0931
Practice Address - Fax:651-287-0967
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 4364103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist