Provider Demographics
NPI:1619902228
Name:O'MALLEY-LAURSEN, JEAN (LP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:O'MALLEY-LAURSEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 AGNES ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3029
Mailing Address - Country:US
Mailing Address - Phone:507-455-2416
Mailing Address - Fax:
Practice Address - Street 1:124 ELTON HILLS LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3567
Practice Address - Country:US
Practice Address - Phone:507-282-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0373103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist