Provider Demographics
NPI:1760427140
Name:BALESTRERY, JEAN EMILY (LICSW, MAC, ACSW)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:EMILY
Last Name:BALESTRERY
Suffix:
Gender:F
Credentials:LICSW, MAC, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3153 GEORGIA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3430
Mailing Address - Country:US
Mailing Address - Phone:952-250-5531
Mailing Address - Fax:
Practice Address - Street 1:348 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5187
Practice Address - Country:US
Practice Address - Phone:952-250-5531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN039128000Medicaid
MN039128000Medicaid