Provider Demographics
NPI:1184828204
Name:ANDERSON JACOB, CHRISTINE M (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:M
Last Name:ANDERSON JACOB
Suffix:
Gender:F
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 1:1492 ARDEN PL
Mailing Address - Street 2:
Mailing Address - City:ARDEN HILLS
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3626
Mailing Address - Country:US
Mailing Address - Phone:651-487-6303
Mailing Address - Fax:
Practice Address - Street 1:2124 DUPONT AVE S STE 300
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2735
Practice Address - Country:US
Practice Address - Phone:612-879-1010
Practice Address - Fax:612-879-0059
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4727103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling