Provider Demographics
NPI:1316009988
Name:ROGNESS, JODI S (LP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:S
Last Name:ROGNESS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 HENNEPIN AVENUE S.
Mailing Address - Street 2:#202
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408
Mailing Address - Country:US
Mailing Address - Phone:612-827-0777
Mailing Address - Fax:612-823-0167
Practice Address - Street 1:3137 HENNEPIN AVENUE S.
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-827-0777
Practice Address - Fax:612-823-0167
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-68281OtherUNITED BEHAVIORAL HEALTH
MN753817100Medicaid