Provider Demographics
NPI:1689673857
Name:THEISEN, JAMES JENKINS (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JENKINS
Last Name:THEISEN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-2120
Mailing Address - Country:US
Mailing Address - Phone:612-237-2752
Mailing Address - Fax:612-237-2752
Practice Address - Street 1:6 E DIAMOND LAKE RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1923
Practice Address - Country:US
Practice Address - Phone:612-237-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3639103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
144M0THOtherBC/BS
61-78532OtherMEDICA
169040OtherUCARE
61-78532OtherMEDICA