Provider Demographics
NPI:1740384742
Name:JOSE, SHERRY KAY (LICSW)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:KAY
Last Name:JOSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LABREE AVE SOUTH
Mailing Address - Street 2:NORTHWEST MEDICAL CENTER
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701
Mailing Address - Country:US
Mailing Address - Phone:218-683-4351
Mailing Address - Fax:218-683-4362
Practice Address - Street 1:120 LABREE AVE SOUTH
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-683-4351
Practice Address - Fax:218-683-4362
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW129311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical