Provider Demographics
NPI:1376593178
Name:SCHWANBERG, JENNIFER SUZANNE (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:SCHWANBERG
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 1:1125 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4675
Mailing Address - Country:US
Mailing Address - Phone:320-235-4613
Mailing Address - Fax:855-625-7406
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:STE 2350
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-229-4918
Practice Address - Fax:320-229-5177
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4005103TC0700X
MNLP4005103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN733513000Medicaid