Provider Demographics
NPI:1417035551
Name:JOSEPH, JENNIFER LYNN (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:SHANDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:5762 213TH ST N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9589
Mailing Address - Country:US
Mailing Address - Phone:651-982-4903
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADWAY ST NE
Practice Address - Street 2:SUITE 185
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2195
Practice Address - Country:US
Practice Address - Phone:612-767-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4669103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN637K9SHOtherBCBS
MNHP66846OtherHEALTH PARTNERS