Provider Demographics
NPI:1417958893
Name:NIEMAND, JACKIE SUE (LIC PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SUE
Last Name:NIEMAND
Suffix:
Gender:F
Credentials:LIC PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6381 OSGOOD AVE N STE 8
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6182
Mailing Address - Country:US
Mailing Address - Phone:651-275-9680
Mailing Address - Fax:651-430-9296
Practice Address - Street 1:6381 OSGOOD AVE N STE 8
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6182
Practice Address - Country:US
Practice Address - Phone:651-275-9680
Practice Address - Fax:651-430-9296
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3518103TC2200X, 103TF0000X, 103T00000X, 103TB0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN56B45NIOtherBLUE CROSS BLUE SHIELD MN
MN6236625OtherUNITED BEHAVIORAL HEALTH
MN154015700Medicaid