Provider Demographics
NPI:1619181492
Name:WETTERSTEN, JENNY (MA, LP)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:WETTERSTEN
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3615
Mailing Address - Country:US
Mailing Address - Phone:218-313-1316
Mailing Address - Fax:
Practice Address - Street 1:1215 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4201
Practice Address - Country:US
Practice Address - Phone:218-313-1316
Practice Address - Fax:218-327-1932
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3555103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62 42586OtherUNITED BEHAVIORAL SYSTEMS
MN1010749OtherPREFERRED ONE
MN8H460WEOtherBCBS OF MINNESOTA