Provider Demographics
NPI:1366643868
Name:ULLOM, JENNIFER ANN (MA, LP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:ULLOM
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:RIZIQ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LP
Mailing Address - Street 1:7513 INLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3954
Mailing Address - Country:US
Mailing Address - Phone:612-998-5162
Mailing Address - Fax:
Practice Address - Street 1:700 TWELVE OAKS CENTER DR
Practice Address - Street 2:STE 204
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4415
Practice Address - Country:US
Practice Address - Phone:612-306-8499
Practice Address - Fax:651-374-9641
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPP161LP5067103T00000X
MNLP5067103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist