Provider Demographics
NPI:1164488847
Name:CEDARBROOK COMMUNITY SERVICES
Entity Type:Organization
Organization Name:CEDARBROOK COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:218-822-3736
Mailing Address - Street 1:PO BOX 2633
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2633
Mailing Address - Country:US
Mailing Address - Phone:218-822-3736
Mailing Address - Fax:
Practice Address - Street 1:8391 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8694
Practice Address - Country:US
Practice Address - Phone:218-822-3736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4642103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty