Provider Demographics
NPI:1558552323
Name:KING, JANE ROLLWAGEN (PSYD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ROLLWAGEN
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SIBLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1941
Mailing Address - Country:US
Mailing Address - Phone:651-256-1204
Mailing Address - Fax:651-291-7378
Practice Address - Street 1:400 SIBLEY ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1941
Practice Address - Country:US
Practice Address - Phone:651-256-1204
Practice Address - Fax:651-291-7378
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4833103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical