Provider Demographics
NPI:1164943601
Name:EDLUND, JENNA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:EDLUND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9352 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9422
Mailing Address - Country:US
Mailing Address - Phone:952-955-4714
Mailing Address - Fax:
Practice Address - Street 1:9352 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-9422
Practice Address - Country:US
Practice Address - Phone:952-955-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6329103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral