Provider Demographics
NPI:1568510824
Name:MCDERMOTT, JENNIFER BETH (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BETH
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6168
Mailing Address - Country:US
Mailing Address - Phone:651-917-3843
Mailing Address - Fax:651-266-7854
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-266-7992
Practice Address - Fax:651-266-7854
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN692635500Medicaid