Provider Demographics
NPI:1568052835
Name:EHALT, JENNIFER (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EHALT
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-4515
Mailing Address - Country:US
Mailing Address - Phone:612-889-8894
Mailing Address - Fax:
Practice Address - Street 1:3200 HIGHWAY 100 S
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2175
Practice Address - Country:US
Practice Address - Phone:952-920-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5623103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical